By signing this form, I have agreed to the HIPAA policies of this practice. I understand the disclosures of the protected health information, may be made by this practice, and the legal duties with my respect to my protected health information.
It is understood that all information given by the patient or family member to a treating clinician is confidential and will not be released, except under special circumstances, without patient consent or consent of legal guardian as described in details in the Notice of Privacy Practices. You can authorize us to release information relating to your treatment to another person, provider or company by signing a Release of Information (ROI) form provided by our office.
Because Riddle Psychiatry is bound by the rules of the Health Insurance Portability and Accountability Act (HIPAA), we are unable to provide any information to any person other than you without your consent. This includes information about your account, appointment times, prescriptions, or any information contained in your records with us.
Please list any persons (and relationship) or agencies that we have your permission to release your information to. This information can be amended by you as needed.