INSTRUCTIONS: complete this entire form. Submit it to our office. This form will be encrypted and stored on our secure database only long enough to migrate your data into our secure offline patient management system. Our server is 100% secure according to H.I.P.A.A. standards. We care about your privacy.
If you have downloaded the digital copy (PDF format) of the orthopedic and Sports Medicine Center’s Notice of Privacy Policies, detailing how your information may be used and disclosed as permitted under federal and state law.
I hereby express that I understand the contents of the Notice and I request the following restrictions concerning the use of my personal medical information: