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Patient Forms via Patient Portal

PLEASE NOTE:

All Patient Forms are available in the Patient Portal. In order to access the Patient Portal, you will need to register for an account. Our system will automatically email new Patients with a registration link, but all Patients have the ability to create an account via the Patient Portal.

PLEASE NOTE - YOU MUST USE THE NAME AND DATE OF BIRTH OF THE ACTUAL PATIENT TO CREATE THE ACCOUNT.


YOUR PRIVACY RIGHTS HAVE BEEN INCREASED.

You now have the right to restrict certain disclosures of Protected Health Information (PHI) by CPC to your insurance carrier or health plan.

Without this restriction your insurance company or other payer may access your entire record. To exercise this right you must choose to pay out-of-pocket in full. To exercise this right, simply talk to your doctor. You may be surprised by how little this costs.


Examples of uses of your health information for treatment purposes are:

An example of use of your health information for payment purposes:

An example of use of your health information for health care operations:


YOUR HEALTH INFORMATION RIGHTS:

The health record and billing records we maintain are the physical property of this office. The information in it, however, belongs to you. You have a right to:

OUR RESPONSIBILITIES:

The provider is required to:

We reserve the right to amend, change, or eliminate provisions in our privacy practices and access practices and to enact new provisions regarding the protected health information we maintain. If our information practices change, we will amend our Notice to reflect these changes. You are entitled to receive a revised copy of the Notice by calling or requesting a copy of our Notice or by visiting the office to obtain a copy.

To Request Information or File a Complaint

If you have questions, would like additional information, or want to report a problem regarding the handling of your information, you may contact the following person: Michael Spellman at 941-753-0064 You may also file a complaint by mailing or e-mailing it to the Secretary of Health and Human Services at 202-619-0257 We cannot, and will not, require you to waive the right to file a complaint with the Secretary of Health and Human Services (HHS) as a condition of receiving treatment from our office. We cannot, and will not, retaliate against you for filing a complaint with the Secretary.

Other Uses and Disclosures

Notification
Unless you object in writing, we may use or disclose your protected health information to notify, or assist in notifying, a family member, personal representative, or other persons responsible for your care including any doctor who you inform us is involved in your care, about your location, about your general condition, about your diagnosis and treatment or your death.