The Health Insurance Portability and Accountability Act (HIPAA) requires all health care providers to provide Notice of Privacy Practices. The notice will inform you of the ways we may use your information and the occasions on which we may disclose this information to others.
The notice will also explain your rights regarding your health information:
- Right to request restriction
- Right to receive confidential communications
- Right to inspect and copy your health information
- Right to amend your health information
- Right to an accounting of disclosures
- Right to a paper copy of the notice
- Right to complain if you feel your privacy has been violated
Honor Community Health may use and disclose protected health information (PHI) about me to carry out Treatment, Payment, and Operations (TPO). Please refer to Honor Community Health’s Notice of Privacy Practices posted in the clinic for a more complete description of such uses and disclosures.
Honor Community Health observes the right to revise its Notice of Privacy Practices at any time. A revised Notice of Privacy Practices may be obtained by forwarding a written request to Honor Community Health at 461 W. Huron, Pontiac, MI 48341- 1601.
With my consent, Honor Community Health may call my home or other designated location and leave a message on voice mail or in person in reference to any items that assist the practice in carrying out TPO, such as appointment reminders, insurance items, and any call pertaining to my clinical care, including laboratory results among others.
Honor Community Health may mail to my home or other designated location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements as long as they are marked “Personal and Confidential”.
Honor Community Health may email or text me appointment reminders and patient statements. I have the right to request that Honor Community Health restrict how it uses or discloses my PHI to carry out the TPO. However, the center is not required to agree to my requested restrictions, but if it does, it is bound by this agreement.
By signing this form, I am consenting to Honor Community Health’s use and disclosure of my PHI to carry out TPO. I understand that I may revoke my consent in writing to the extent that the practice has already made disclosures in reliance to my prior consent. If I do sign the consent, Honor Community Health may decline to provide treatment to me.
For more information about this notice or about Honor Community Health’s privacy policies, please contact by mail or phone:
Honor Community Health
461 West Huron Street
Pontiac, MI 48341