CLAYMAN THYROID CANCER CENTER/ Clayman Thyroid Center

Clayman Thyroid Center also called the Thyroid Cancer Center
5959 Webb Road
Tampa
FL 33615

Consent for Purposes of Treatment, Payment and Healthcare Operations

I consent to the use or disclosure of my protected health information by the Clayman Thyroid Cancer Center for the purpose of diagnosing or providing treatment to me, obtaining payment for my health care bills or to conduct health care operations of Clayman Thyroid Cancer Center. I understand that diagnosis or treatment of me by the surgeons at the center may be conditioned upon my consent as evidenced by my signature on this document, or by my electronic acknowledgment that I have read and understand it. I understand that any information gathered by the Clayman Thyroid Cancer Center will be done so only when I allow it and have consented to it, understanding that secure web servers and accepted encryption technology will be used to collect this information so that it is protected and not available to the public. No information will be gathered from me at any time unless I purposefully agree to it and actively engage in the process.

I understand I have the right to request a restriction as to how my protected health information is used or disclosed to carry out treatment, payment or healthcare operations of the practice. The Clayman Thyroid Cancer Center is not required to agree to the restrictions that I may request. However, if the Clayman Thyroid Cancer Center agrees to a restriction that I request, the restriction is binding on the Clayman Thyroid Cancer Center.

I have the right to revoke this consent, in writing, at any time, except to the extent that Dr Gary Clayman, or The Clayman Thyroid Cancer Center has taken action in reliance on this consent.

My "protected health information" means health information, including my demographic information, collected from me and created or received by my physician, another health care provider, a health plan, my employer or a health care clearinghouse. This protected health information relates to my past, present or future physical or mental health or condition and identifies me, or there is a reasonable basis to believe the information may identify me.

I understand I have a right to review the Clayman Thyroid Cancer Center's Notice of Privacy Practices prior to signing this document. The Clayman Thyroid Cancer Center's Notice of Privacy Practices has been provided to me. The Notice of Privacy Practices describes the types of uses and disclosures of my protected health information that will occur in my treatment, payment of my bills or in the performance of health care operations of the Clayman Thyroid Cancer Center. The Notice of Privacy Practices for the Clayman Thyroid Cancer Center's is also provided at their principle office located at 2352 Creel Lane, Wesley Chapel, Florida 33544; and on the Clayman Thyroid Cancer Center's website at www.thyroidcancer.com/privacy-policy. This Notice of Privacy Practices also describes my rights and the Clayman Thyroid Cancer Center's duties with respect to my protected health information.

The Clayman Thyroid Cancer Center reserves the right to change the privacy practices that are described in the Notice of Privacy Practices. I may obtain a revised notice of privacy practices by accessing www.thyroidcancer.com, calling the office and requesting a revised copy be sent in the mail or asking for one at the time of my next appointment.

By accessing this page and checking the appropriate box on the Insurance Form and/or the New Patient Form, I acknowledge that I have seen and agree to these privacy terms.

Communication by Email with the Practice

• HIPAA stands for the Health Insurance Portability and Accountability Act to establish privacy and security protections for health information.
• Information stored on our computers are encrypted.
• Most popular email services (ex. Hotmail®, Gmail®, Yahoo®) do not utilize encrypted email.
• When we send you an email or you send us an email, the information that is sent is not encrypted. This means a third party may be able to access the information and read it since it is transmitted over the Internet. In addition, once the email is received by you, someone may be able to access your email account and read it.
• Email is a very popular and convenient way to communicate for a lot of people so in their latest modification to the HIPAA act; the federal government provided guidance on email and HIPAA.
• The guidelines state that if a patient has been made aware of the risks of unencrypted email, and if that same patient provides consent to receive health information via email; then a health entity may send that patient personal medical information via unencrypted email.
• Since e-mail can be used to spread viruses please don’t send attachments in the emails. For example, some virus can cause e-mail messages to be sent to people who you do not intend to send e-mail to; therefore you should install and maintain virus protection software on your PC.

By consenting to the use of e-mail with the Clayman Thyroid Center and the Practice, you agree that:
• Clayman Thyroid Center may forward e-mails as appropriate for diagnosis, treatment, reimbursement, and other related reasons. As such, Clayman Thyroid Center employees, medical staff, and other than the recipient, may have access to e-mails that you send. Such access will only be to people who have a right to access your e-mail to provide services to you. Otherwise, Clayman Thyroid Center will not forward e-mails to independent third parties without your prior written consent, unless as authorized or required by law.
• Although Clayman Thyroid Center will try to read and respond promptly to your e-mails; the staff may not read your e-mail immediately. Therefore, you should not use e-mail to communicate with the Clayman Thyroid Center or any of its staff, nurses or doctors if there is an emergency or where you require an answer in a short period of time.
• If your e-mail requires or asks for a response and you have not received a response within a reasonable time period, it is your responsibility to follow up directly with Clayman Thyroid Center.
• You should carefully consider the use of e-mail for the communication of sensitive medical information such as but not limited to; information regarding sexually transmitted diseases, AIDS/HIV, mental health, developmental disability, or substance abuse.

This form is required of all patients seeking medical treatment from any healthcare provider under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) as passed by Congress and being enforced April, 2003.

Read full text of the Clayman Thyroid Cancer Center Notice of Privacy Practices