During a Group Visit, or Shared Medical Appointment, it is possible that some of my individually identifiable health information will be disclosed. For example, at a group visit for weight management, it might be assumed that everyone attending has a medical condition that could be improved by better nutrition and fitness habits. I have read and understand the following statements about my rights:

I realize that I have the option to be seen individually. I understand that I am not required to sign this form to receive health care treatment. I understand that discussions may occur regarding individually identifiable health information during a group visit. It is possible that the information that is used or disclosed in a group visit may be re-disclosed by other participants in the group visit. I have been notified of this potential disclosure, and I voluntarily wish to participate in the group visit. I understand that anything that is discussed in the group visit will stay confidential within the group, and I agree not to discuss matters relating to other members in the group with anyone outside of the group.

This Group Visit HIPAA Notice Regarding Use and Disclosure supplements the Notice of Privacy Practice originally provided to me.