Notice of Privacy Practices & HIPAA Acknowledgment

Required by federal law. Please read and sign.

Required — All Patients

1. Patient Information

Patient Name *

Date of Birth *

2. Notice of Privacy Practices (Summary)

How We Use and Disclose Your Health Information

Advanced Medical Imaging is committed to protecting your health information. We use your protected health information (PHI) to:

Treatment: To provide, coordinate, and manage your imaging care and related services.
Payment: To bill your insurance company or collect payment for services.
Operations: For administrative functions, quality improvement, and staff training.

Disclosures Required or Permitted by Law

We may disclose your PHI without your authorization when required by law, such as for public health activities, reporting to government agencies, complying with court orders, or responding to law enforcement requests as permitted by HIPAA.

Your Rights Regarding Your Health Information

Request restrictions on certain uses and disclosures
Request confidential communications of your PHI
Inspect and obtain a copy of your records
Request corrections to your records
Receive an accounting of certain disclosures
Receive a paper copy of this Notice
File a complaint if you believe your privacy rights have been violated

Authorizations

Other uses and disclosures of your PHI not described above will be made only with your written authorization. You may revoke such authorization at any time in writing, except to the extent we have already acted upon it.

Contact & Complaints

For questions about our privacy practices or to file a complaint, contact our Privacy Officer at:

Advanced Medical Imaging
9555 Seminole Blvd, Suite 101, Seminole, FL 33772
Phone: (727) 398-5999 | Fax: (727) 231-0772
Email: scheduling@advancedimg.com

You may also file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights. Complaints will not affect the quality of your care.

3. Optional Authorizations

Release of Results to Authorized Contacts

You may authorize us to discuss your results with family members or other individuals:

Name 1

Relationship

Name 2

Relationship

Marketing & Communications

I consent to receive appointment reminders and health information via text/email.I consent to receive general health newsletters and service updates from Advanced Medical Imaging.

4. Acknowledgment

By signing below, I acknowledge that I have been offered a copy of the Notice of Privacy Practices for Advanced Medical Imaging and that I understand my rights regarding my protected health information as described in the Notice.

Patient / Guardian Signature *

Sign above

Date *

If signing on behalf of patient — Name & Relationship

For Staff Use Only

Staff Initials

Date Presented

Patient Declined? (note reason)

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