HIPAA Information and Consent Form

The Health Insurance Portability and Accountability Act (HIPAA) provides safeguards to protect your privacy. Implementation of HIPAA requirements officially began on April 14, 2003. Many of the policies have been our practice for years. This form is a “friendly” version. A more complete text is posted in the office and on

What this is all about: Specifically, there are rules and restrictions on who may see or be notified of your Protected Health Information (PHI). These restrictions do not include the normal interchange of information necessary to provide you with office services. HIPAA provides certain rights and protections to you as the patient. We balance these needs with our goal of providing you with quality professional service and care. Additional information is available from the U.S. Department of Health and Human Services. www.hhs.gov

We have adopted the following policies:

1.  Patient information will be kept confidential except as is necessary to provide services or to ensure that all administrative matters related to your care are handled appropriately. This specifically includes the sharing of information with other healthcare providers, health insurance payers as is necessary and appropriate for your care. Those records will not be available to persons other than office staff. You agree to the normal procedures utilized within the office for the handling of charts, patient records, PHI and other documents or information.

2. It is the policy of this office to remind patients of their appointments. We do this by text messaging. We may send you other communications for educational purposes, informing you of changes to office policy, and new technology that you might find valuable or informative.

3. You understand and agree to inspections of the office and review of documents which may include PHI by government agencies or insurance payers in normal performance of their duties. Other exceptions include: Public Health issues as required by law, Health Oversight activities, Abuse or Neglect, Legal/judicial Proceedings, Law Enforcement, Criminal Activity, to prevent or lessen a serious threat to health and safety, and Workers’ Compensation. 

4. You agree to bring any concerns or complaints regarding privacy to the attention of the office manager or your therapist.   Call 507-676-6834 and request to talk with the company president. 

5. Your confidential information will not be used for the purposes of marketing or advertising of products, goods or services.

6. We agree to provide patients with access to their records in accordance with state and federal laws.

7. We may change, add, delete or modify any of these provisions to better serve the needs of the both the practice and the patient.

8. You have the right to request restrictions in writing for the use of your protected health information and to request change in certain policies used within the office concerning your PHI. However, we are not obligated to alter internal policies to conform to your request.