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(links outside of site)

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PATIENT HEALTH PRIVACY INFORMATION

The Health Insurance Portability and Accountability Act of 1996 or HIPAA was passed by Congress and signed into law to ensure that patient privacy, was protected at both the State and Federal level. At Urgent Care Matters, we take these matters very seriously and have instituted numerous internal and external measures to maximize compliance. Each employee at Urgent Care Matters has received and completed HIPAA Compliance Training designed to educate them on your rights as protected by law.

To aid us in the protection of your Privacy Rights, Urgent Care Matters employs the use of the following forms.  We ask that you become familiar with these documents and be prepared to acknowledge your review of these rights.

Forms for Patient Rights
The following forms are to be used in connection with patient's guaranteed rights under HIPAA:

  • Patient Health Records Access — This form is used to request access to a patient's record. The records can be provided in person by mail, email or fax.
    • English (PDF,342 KB - links outside of site)
    • Spanish (PDF,169 KB - links outside of site)

  • *Confidential — This form is used for a patient to request alternate methods of communication, such as email, cell phone, or a different address than the home address on file.
    • English (PDF,328 KB - links outside of site)
    • Spanish (PDF,176 KB - links outside of site)

  • *Restrictions — This form is used to request a limitation or restriction of disclosure of patient PHI to a health plan or carrier when a private pay patient has paid in full. The form is also used to request a limitation or restriction of disclosure of patient’s PHI to others such as a family member physician or employer (this does not apply to workers compensation).
    • English (PDF,98 KB - links outside of site)
    • Spanish (PDF,174 KB - links outside of site)

*These rights may be limited for certain services, such as workers compensation.