COVID-19 alert
CORONAVIRUS DISEASE (COVID-19) - UNITED STATES
OUR OFFICE IS TAKING SERIOUS PRECAUTIONS TO HELP LIMIT THE SPREAD OF COVID-19 OUT OF RESPECT FOR OUR IMMUNOCOMPROMISED PATIENTS, WE REQUIRE THAT EVERYONE WEAR A MASK WHEN COMING INTO OUR OFFICE.
EVERYONE'S TEMPERATURE WILL BE TAKEN BEFORE ENTERING OUR CLINIC. YOU WILL BE ASKED TO FILL OUT A COVID-19 QUESTIONNAIRE.
IF YOU HAVE ANY SYMPTOMS OF COVID-19 OR HAVE RECENTLY TRAVELED OUT OF THE AREA, PLEASE CALL OUR OFFICE @208-529-9292.

HIPPA FORM

PLEASE REVIEW IT CAREFULLY
ADDENDUM TO NOTICE OF USE AND DISCLOSURES*
THIS ADDENDUM PROVIDES SPECIFIC DIRECTIONS FOR USE AND DISCLOSURE
OF YOUR MEDICAL INFORMAITON

Contact Us

    ADDITIONAL PHI DISCLOSURE  


I hereby provide authorization for the following persons to receive my PHI. If PHI (personal health information) is disclosed under your authorization to person(s) entities that are not subject to federal or state privacy laws, it may be redisclosed and no longer protected. The purpose of this disclosure of my PHI   is "At my request". I authorize discloser of my PHI   to the following person(s) entities:

NON-DISCLOSURE


I DO NOT  want the following types of my PHI disclosed. Additional I do not authorize disclosure of my PHI to the identified person(s)/entities:

FINANCIAL DISCLOSURE


I hereby provide authorization for the following persons/entities to receive and/or inquire about my Financial obligations associated with the care I have received.

I have read, understand, and agree to all the provisions of this Financial Policy which includes your agreement for payment at time of treatment unless other arrangements are made prior to service or treatment. I hereby authorize the use and discloser of my individually identifiable PHI as stated in the Notice of Use and Disclosures except as excluded by this the addendum.

*This is an addendum to the NOTICE OF USE AND DISCLOSURES. All information on Notice of Use and Disclosures as well as the Financial Policy apply in association with this document