HIPAA Privacy Acknowledgment Form

Purpose

This form acknowledges that you, the patient, have been informed of how your personal health information (PHI) may be used and disclosed by MediDuce Wellness in accordance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

Our goal is to protect the privacy and security of your medical information while ensuring you receive the best possible care.

Use and Disclosure of Health Information

Your PHI may be used and shared for purposes such as:

Providing, coordinating, or managing your healthcare and treatment

Communicating with laboratories, pharmacies, and medical providers involved in your care

Processing billing, payment, and insurance claims

Performing healthcare operations, quality reviews, and compliance audits

Your PHI will not be sold, shared, or disclosed to any third parties for non-medical purposes without your written authorization.

Your Rights Under HIPAA

As a patient, you have the right to:

Access and obtain copies of your medical records

Request corrections to your medical information

Request restrictions on how your information is shared

Receive a list of disclosures of your PHI

File a complaint if you believe your privacy rights have been violated

You can exercise these rights by contacting MediDuce Wellness at [email protected].

Confidentiality & Data Security

MediDuce Wellness uses secure, encrypted systems to store and transmit all patient information.
All telehealth communications are conducted over HIPAA-compliant platforms.
We make every reasonable effort to safeguard your privacy and prevent unauthorized access to your data.

Patient Acknowledgment

By ticking the box, you acknowledge and understand that:

You have been informed of how your protected health information (PHI) may be used and disclosed.

You understand your rights regarding your PHI under HIPAA.

You have had the opportunity to ask questions regarding privacy practices.

You consent to the collection, use, and disclosure of your PHI by MediDuce Wellness for the purposes of treatment, payment, and healthcare operations.