• General Patient Information

  • General Patient Information

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  • Patient Medical History

  • Healthy & Unhealthy Habits

  • A Notice of Privacy Practices (NPP) is provided to all patients. This Notice of Privacy Practices identifies:

    How medical information about you may be used or disclosed;
    Your rights to access your medical information, amend your medical information, request an accounting of disclosures of your medical information, and request additional restrictions on our uses and disclosures of that information;
    Your rights to complain if you believe your privacy rights have been violated; and
    Our responsibilities for maintaining the privacy of your medical information.

  • Per federal law, Concierge Health & Rejuvenation Solutions, LLC is committed to protecting the privacy of your medical information, neither this company nor its employees or owners or assignees will release any medical or financial information to any person or agency without the expressed written or witnessed consent of the Responsible party designated above.

     The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a federal law that governs the use and disclosure of a person’s health information. Our “Notice of Private Practice” provides information about how we may we disclose protected health information about you. The Notice contains a “Patient Rights “describing your rights under the law. The following statements cover the basics of your rights as a patient under HIPPA.

    Protected health information may be disclosed or used for treatment, payment, or health care operations.
    We have a Notice of Private Practice and you have the right to review a detailed copy of our Notice before signing this HIPAA Patient Consent.
    We reserve the right to change the terms of our Notice of Private Practices
    If we change our Notice, you may obtain a revised copy by contacting our office.
    You have the right to restrict the uses of your protected health information.
    You may revoke this HIPAA Consent in writing at any time. However, such a revocation shall not affect any disclosures we have already made in reliance on your prior Consent.

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