PRIVACY ACT DOCUMENT INSTRUCTIONS Although physicians have a 4000-year tradition of maintaining patient confidentiality, the United States Congress enacted the Privacy Act of 2001. This law governs how health care providers must store, secure, and transmit personal health information. We are required to give you certain notices and to receive certain instructions from you indicating how you want the doctor and the office staff to handle your personal health information. This web site provides the necessary documents for you to review and to sign by the time of your first visit to the office so you can take care of these matters at your own convenience, if you so choose. The new law requires us to provide you a NOTICE OF OUR PRIVACY PRACTICES at your first visit after April 14, 2003. The new law also requires us to document that we have provided you this notice and that you consent to our privacy practices. Please view and read either the 1 page ABRIDGED NOTICE OF PRIVACY PRACTICES or the 9 page COMPLETE NOTICE OF PRIVACY PRACTICES. Please download, print out, and sign in the appropriate location the document entitled CONSENT TO PRIVACY PRACTICES, indicating whether you have read the abridged or complete version of the notice; bring the signed document to the office and give it to the receptionist. If you do not agree with the privacy practices of this medical practice and if you do not wish to sign consent for our privacy practices, Federal law does not allow the doctor to see you. The new law permits us to use your personal information for treatment, payment, and operational purposes. The new law does not permit us to discuss or share your personal health information with your spouse, children, or any other concerned individual without your specific written authorization. We have no way of knowing or assuming which parties may be the legitimate recipients of such information in your case unless you tell us. Accordingly, you will find a form entitled SURROGATE - TELEPHONE AUTHORIZATION. Please download the form, print it out, and fill in the names of those people with whom we can communicate if you are incapacitated or unavailable to communicate. You may have concerned relatives in town or out of town who call and want to speak to the doctor about your condition, but the Privacy Act forbids us to talk to anyone whose name is not on the list. Also, if you wish to permit us to leave telephone messages for you on your answering machine or voice mail, please initial and date the second page of this form in the designated area. Bring the signed form to the office at the time of your first visit and give it to the receptionist. If you don't understand the form or if you have questions, the receptionist will be glad to help you. We are firmly committed to preserving your privacy and confidentiality. The Privacy Act requires us to have these signed documents on file in the medical chart of every patient we see after April 14, 2003.