RELEASE OF INFORMATION
Your private health information is strictly confidential and contains privileged medical information. To assure this confidentiality, information contained in your medical record will not be released to anyone, including your family members, without your written permission to do so. We recommend that pre-arrangements for the release of your medical information be discussed with your physician. We require that you complete and sign the TPMG Notice of Privacy Practices Acknowledgement and Consent form which discloses who, if anyone, has your consent regarding your protected health information (PHI): (This form is commonly referred to as the HIPAA form).
If you have advance directives such as an Advance Medical Directive or a Living Will, please provide us with a copy for inclusion in your private health information. It is your responsibility to help keep your private health information current. Please advise our staff of any changes in your name, address, telephone number or insurance carrier at the earliest opportunity.
We will gladly provide copies of your private health information for referring physicians or other medical professionals who may need them to provide you care. Please allow at least 10 working days to process requests for medical records.
We reserve the right to charge for copying private health information, as well as for preparing disability forms, insurance applications, and other written documents relating to your diagnosis and treatment. All private health information including x-rays performed at our office remains the property of TPMG.
Authorization to Release Information Form: