Notice of Privacy Practices

The Vanderbilt Wellness clinic is required by law to maintain the privacy of, and provide individuals with, this notice of our legal duties and privacy practice with respect to protected health information. We are legally bound by the terms of this notice currently in effect. Please let us know if you have any questions regarding this notice.

HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED, DISCLOSED,

AND HOW YOU CAN GET ACCESS. PLEASE REVIEW CAREFULLY

“Protected Health Information,” or PHI, is information about you. This includes demographic information and any information that can identify you and/or relate to your past, present, or future physical and/or mental health conditions and related health services. Your PHI is used in this clinic solely for your care and treatment. It cannot be used for research or advertisement purposes without your explicit permission. PHI cannot be disclosed with any person, business, or entity that is not you, without your explicit permission. You can directly provide us who you would like to have access or they may provide a copy of a Healthcare Power of Attorney. You may access your PHI through the EMR portal or you may request a paper or disc copy from the clinic for a fee. 

Your PHI may be used and disclosed by your provider, our office staff, and those involved with your care and treatment for the purpose of providing health care services to you or as required by law. Examples are, and not limited to, if we were to refer you to a specialist or your PCP requested information about your care here.

Is there anyone you would like to put on file to be able to access your PHI. This person will be able to call the clinic on your behalf to request refills, make payments, or request your PHI. If there is no one, please print “No one”. This will be considered to be in effect until updated.

Name of authorized person(s), their relationship to you, and their phone number:

______________________________________________________________________________________________________________________________________________________________________________________________________________________

I, ___________________________________________, have read this notice and certify that I understand and agree to its contents.

Signature: __________________________________________ Date: ______________