As a patient of Spectra Health, I understand that under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), I have certain rights to privacy with regards to my protected health information. Additionally, I understand that if I choose to receive services for substance use disorder treatment at Spectra Health, that these records have further privacy protections covered by 42 CFR regulations (Part 2).
I understand my health information can and will be used to:
- Conduct, plan and direct my treatment and follow-up among my health care providers who may be involved in that treatment directly or indirectly.
- Obtain payment from third-party payers.
- Conduct normal health care operations such as quality assessments and practitioner certifications.
HIPAA and Part 2 Covered Services
By signing below, I acknowledge that I have received, read, and understand Spectra Health's Notice of Privacy Practices document describing the uses and disclosures of my health information as it relates to HIPAA and Part 2 protections (when applicable). I understand that I may ask questions about the information contained in this notice at any time, and that I may contact Spectra Health at any time to request a current copy of the Notice of Privacy Practices document.
Patient Rights and Responsibilities
By signing below, I acknowledge that I have received Spectra Health's Patient Rights and Responsibilities, and Zero Tolerance Statement document describing the general expectations for receiving services at Spectra Health. I understand that I may ask questions about the information contained in this notice at any time, and that I may contact Spectra Health to request a current copy of the Patient Rights and Responsibilities, and Zero Tolerance Statement document.