At times our office may need to contact you with appointment reminders, information about
treatment, or other health related information. By signing below, you are giving us authorization to
contact you with these reminders/information and understand that
Information that we use or disclose based on this authorization may be subject to re -
disclosure by anyone who has access to the reminder or information and may no longer be
protected by the federal privacy rules.
You may restrict the individuals or organizations to which your health care information is
released, or revoke your authorization at any time; however, the revocation must be in writing and
will become effective once we receive the revocation. If you are required to give your authorization
as a condition of obtaining insurance, the insurance company may have a right to your health
information if they decide to contact any of your claims.
You have the right to refuse any part of this authorization without affecting your treatment or
the methods use to obtain reimbursement for your care. You may inspect or copy the information
that we use to contact you to provide appointment reminders, information about treatment
alternatives, or other health related information at any time (§164.524).
I authorize the use or discloser of my health information as described above. This notice is effective
as of the date above and expires seven years from the date I last received services in this office.
This notice describes how medical information about you may be used or disclosed and how you can get access to
information. Please review it carefully.
Tennessee Sports Medicine Group/SquareOne is required by law to protect the privacy of your personal health
information, provide this notice about our information practices, and follow the information practices that are described
Tennessee Sports Medicine Group/SquareOne uses your personal health information primarily for treatment,
obtaining payment for treatment, conducting internal administration activities and evaluating the quality of care that we
provide. For example, Tennessee Sports Medicine Group/SquareOne may use your personal health information to contact
you to provide appointment reminders, or information about treatment alternatives or other health related benefits that could
be of interest to you. Tennessee Sports Medicine Group/SquareOne may use or disclose your personal health information
without prior authorization for public health purposes, for research studies, for auditing purposes, and for emergencies. We
also provide information when required by law.
In any other situation, Tennessee Sports Medicine Group/SquareOne policy is to obtain your written authorization
before disclosing your personal health information. If you provide us with a written authorization to release your information
for any reason, you may later revoke that authorization to stop further disclosures at any time.
Tennessee Sports Medicine Group may change its policy at any time. When changes are made, a new Notice of
Patient Information Practices will be posted in the waiting room and patient treatment areas and will be provided to you
at your next visit. You may also request a copy of Notice of Patient Information Practices at any time.
You have the right to review or obtain a copy of your personal health information at any time. You have the right to
request that we correct inaccurate or incomplete information in your records. You also have the right to request a lit of
instances where we have disclosed your personal information for reasons other than treatment, payment, or other related
You may also request in writing that we not use or disclose your personal health information for treatment,
payment, and administrative purposes except when specifically authorized by you, when required by law, or in
emergency circumstances. Tennessee Sports Medicine Group/SquareOne will consider all requests on a case-by-case
basis, but the practice is not legally required to accept them.
If you are concerned that Tennessee Sports Medicine Group/SquareOne may have violated your privacy rights, or
if you disagree with any decisions we have made regarding access or disclosure of your personal health information, please
contact our manager. You may also send a written complaint to the US Department of Health and Human Services.
I have read and fully understand Tennessee Sports Medicine Group/SquareOne Notice of Information Practices. I
understand that Tennessee Sports Medicine Group/SquareOne may use or disclose my personal health information for the
purpose of providing treatment, obtaining payment, evaluating the quality of services provided, and any administrative
operations related to treatment or payment. I understand that I have the right to restrict how my personal information is used
and disclosed for treatment, payment, and administrative operations if I notify the practice. I also understand that Tennessee
Sports Medicine Group/SquareOne will consider restriction on a case-by-case basis, but does not have to agree to requests
I hereby consent to the use and disclosure of my personal health information as noted in Tennessee Sports Medicine
Group/SquareOne Notice of Information Practices. I understand that I retain the right to revoke this consent by notifying the
practice in writing at any time.
The Information you may release subject to this signed release form is as follows:
Release my protected health information from the following physician/facility