HIPAA/Privacy Practices

• If you would like to sign up for FollowMyHealth please contact the office and ask for a patient portal invite or fill out the form below.

Use and Disclosure of Your Protected Health Information

Your protected health information will be used by RVA Pediatrics, P.C. or disclosed to others for the purposes of treatment, obtaining payment, or supporting the day-to-day health care operations of the practice.

Notice of Privacy Practices

You should review the Notice of Privacy Practices for a more complete description of how your protected health information may be used or disclosed. You may review the notice prior to signing this consent.

Requesting a Restriction on the Use or Disclosure of Your Information

You may request a restriction on the use or disclosure of your protected health information. RVA Pediatrics, P.C. may or may not agree to restrict the use or disclosure of protected health information. If RVA Pediatrics, P.C. agrees to your request, the restriction will be binding on the practice. Use or disclosure of protected information in violation of an agreed upon restriction will be a violation of the federal privacy standards.

Revocation of Consent

You may revoke this consent to the use and disclosure of your protected health information. You must revoke this consent in writing. Any use or disclosure that has already occurred prior to the date on which your revocation of consent is received will not be affected.

Reservation of Right to Change Privacy Practices

RVA Pediatrics, P.C. reserves the right to modify the privacy practices outline in the notice.

Signature

I have reviewed this consent form and give my permission to RVA Pediatrics, P.C. to use and disclose my health information in accordance with it

FORM

Notice of Privacy Practices

Privacy Practices Acknowledgement

ACKNOWLEDGEMENT FORM

I have received the Notice of Privacy Practices, and I have been provided an opportunity to review it.

FORM