DUANE M. GELS, MD
129 Lubrano Drive, Suite 200 Annapolis, MD 21401
227 N Liberty Street Centreville, MD 21617
Phone 410.573.1600 Fax 410.573.5841 www.annapollsallergy.com
Our Notice of Privacy Practices provides information about how we may use or disclose protected health information.
The notice contains a patient's rights section describing your rights under the law. By your signature, you ascertain that you have reviewed our notice before signing the consent.
The terms of the notice may change. If so, you will be notified at your next visit to update your signature date.
You have the right to restrict how your protected health information is used and disclosed for treatment, payment, or healthcare operations. We are not required to agree with this restriction, but if we do, we shall honor this agreement. The HIPAA (Health Insurance Portability and Accountability Act of 1996) law allows for the use of the information for treatment and payment.
By signing this form, you consent to our use and disclosure of your protected healthcare information. You have the right to revoke this consent in writing, signed by you. However, such revocation will not be retroactive.
By signing this form, I understand that:
- Protected health information may be disclosed for treatment and payment.
- The practice has the right to restrict the use of the information, but the patient does not have to agree to those restrictions.
- The patient has the right to revoke this consent in writing at any time and all full disclosures will then cease.
- The practice has the right to obtain information from your medical providers as well as information from HIE CRISP which will help us to better understand your medical history.
- You consent that we may include in your PHI electronic images relevant to your care submitted by you or obtained at your visit.