HIPAA Compliance Requirement Forms

If you would like to authorize Perlman Clinic to disclose your Protected Health Information (“PHI”) to a specific person or over voicemail, please download the following HIPAA Compliance Requirement Form, fill it out, and email it to [email protected].

HIPAA Statement

Updated: September 23, 2015


The Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) requires us to ask each of our patients to acknowledge receipt of our Notice of Privacy Practices. Perlman Clinic must take steps to protect the privacy of your Protected Health Information (“PHI”) in accordance with HIPAA. PHI includes information that we have created or received regarding your health care, including payment and billing for your health care. In addition to your medical records, PHI includes personal information such as your name, social security number, address, and phone number.

Under federal law, we are required to: (i) protect the privacy of your PHI and Perlman Clinic therefor requires our employees to maintain the confidentiality of PHI; (ii) provide you with this Notice of Perlman Clinic Privacy Practices explaining our duties and practices regarding your PHI; and (iii) follow the practices and procedures set forth in this Notice of Perlman Clinic Privacy Practices.

You understand that as a part of your healthcare, Perlman Clinic originates and maintains paper and/or electronic records describing your health history, symptoms, examination and test results, diagnoses, treatment and any plans for future care and treatment. You understand that this information serves as follows:

A basis for planning your care and treatment;
A means of communication among health professionals who contribute to your care;
A source of information for applying your diagnosis and treatment to your bill;
A means by which a third-party payer can verify services billed were provided;
A tool for routine healthcare operations, such as assessing quality and reviewing the competence of healthcare professionals.

By using our services you understand that as a part of Perlman Clinic’s treatment, payment and/or healthcare operations, it may become necessary to disclose your PHI to another entity and you consent to such disclosure for these permitted uses including disclosures via fax and sharing of electronic medical records. Additionally, PHI may be released without your authorization for (i) legal and/or governmental purposes and (ii) for certain miscellaneous circumstances, such as to a person accompanying you for treatment or to an authorized public party for disaster relief purposes; all as allowed under HIPAA.

Except for the situations listed above, we will use and disclose your PHI only with your written authorization. We will not disclose your PHI in the following cases, unless you give us written permission: (i) third party marketing purposes; (ii) sale of your information; and (iii) most sharing of psychotherapy notes. Federal and state laws provide special protections for specific kinds of PHI and require authorization from you before we can disclose such PHI. In these situations, we will contact you for the necessary authorization. In some situations, you may revoke your authorization. If you have questions about these laws, please contact the Privacy Officer at 858.554.1212.

Email and Text: You are advised that email and text are not secure methods of communication. If you email or text us you agree to our communication by use of email or text and you agree to the risks. If in the future you prefer to not exchange health information by email or text, please let us know by sending an email to [email protected] or texting 858.554.1212.

Without limitation, you have the right to request: (i) restrictions on the disclosure of your PHI; (ii) ask for a specific means of communication; (iii) request an electronic or paper copy of your PHI; (iv) an amendment to your PHI; (v) seek an accounting of the disclosures made of your PHI; (vi) a paper copy of this Notice; and (vii) a written notification of any breach of the confidentiality of your PHI. All requests must be in writing and in certain circumstances a request may be denied or require the payment of a fee. In any such circumstances we will explain our response. You may file a complaint if you believe your privacy rights have been violated. You can file a written complaint with us and/or with the U.S. Department of Health and Human Services Office for Civil Rights. Their address is 200 Independence Avenue, S.W., Washington, D.C. 20201. You may also contact them by calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints.