HIPAA Privacy Practices & Forms

Your Infor­ma­tion. Your Rights. Our Responsibilities.

Noth­ing is more impor­tant than ensur­ing your pri­va­cy. At Duly Health and Care, we under­stand that your pri­va­cy is vital­ly impor­tant. As your med­ical provider, we take proac­tive mea­sures to safe­guard your infor­ma­tion. We under­stand that with each office vis­it, you are plac­ing your trust in us. We will make every effort to ensure this trust is not breached, and that your pri­va­cy is pro­tect­ed.

This Notice was devel­oped to pro­vide you with infor­ma­tion regard­ing your rights to pri­va­cy and con­fi­den­tial­i­ty. It con­tains our poli­cies regard­ing pri­va­cy accord­ing to the Health Insur­ance Porta­bil­i­ty and Account­abil­i­ty Act (HIPAA) rules and reg­u­la­tions. We encour­age you to read this infor­ma­tion thor­ough­ly so that you are ful­ly informed about our poli­cies and pro­ce­dures. We wel­come any ques­tions you may have regard­ing this information.

Notice of Pri­va­cy Practices

Phone/​Verbal Consent

Use this form to doc­u­ment the pre­ferred phone num­bers to con­tact you and whether or not our staff can leave detailed mes­sages. Also use this form to list any person(s) with whom we may share details about your care, includ­ing billing infor­ma­tion. Please indi­cate whether this may include sen­si­tive health infor­ma­tion (SHI) such as men­tal health, genet­ic test­ing, drug and/​or alco­hol abuse treat­ment, and sex­u­al­ly trans­mit­ted dis­ease (STDs) includ­ing HIV/AIDS. Com­plete the below form to update your con­tact numbers.

Con­sent for Ver­bal Release of Infor­ma­tion Form

Patient Amend­ment Requests

You have the right to request a change or amend­ment to your pro­tect­ed health infor­ma­tion Duly Health and Care main­tains in your med­ical record. To exer­cise your right to request an amend­ment, please com­plete the below form. *If you need to update your demo­graph­ic infor­ma­tion, please log in to MyChart or con­tact cus­tomer ser­vice at 866−734−7680.

Patient Amend­ment Request Form

Patient Request­ed Restriction

You have the right to request restric­tions as to how your pro­tect­ed health infor­ma­tion (PHI) may be used and/​or dis­closed to car­ry out pay­ment. To exer­cise your right to request a restric­tion on the dis­clo­sure of your PHI, please com­plete the below form. 

Patient Request­ed Restric­tion Form

Care Every­where Opt-Out

Duly Health and Care par­tic­i­pates in Epic’s Care Every­where to share your med­ical record via secure, encrypt­ed con­nec­tions. This enables your treat­ing provider(s) to access your health infor­ma­tion when you are receiv­ing care out­side of Duly Health and Care. This infor­ma­tion shared includes your med­ical his­to­ry, pre­vi­ous diag­noses, test results (i.e. labs and imag­ing), cur­rent med­ica­tions, aller­gies, and progress notes. This con­nec­tion allows for real-time access with­out hav­ing to wait for records to be trans­ferred between facilities.

You may opt out if you do not want your record shared with your treat­ing provider(s) through Care Every­where. If you
opt out, you also have the right to opt back in at any time. To opt-out of Care Every­where, please com­plete the below form. 

Care Every­where Opt-Out Form