HIPAA Privacy Practices & Forms
Notice of Privacy Practices
Your Information. Your Rights. Our Responsibilities.
Nothing is more important thank ensuring your privacy. At Duly Health and Care, we understand that your privacy is vitally important. As your medical provider, we take proactive measures to safeguard your information. We understand that with each office visit, you are placing your trust in us. We will make every effort to ensure this trust is not breached, and that your privacy is protected.
This Notice was developed to provide you with information regarding your rights to privacy and confidentiality. It contains our policies regarding privacy according to the Health Insurance Portability and Accountability Act (HIPAA) rules and regulations. We encourage you to read this information thoroughly so that you are fully informed about our policies and procedures. We welcome any questions you may have regarding this information.
Use this form to document the preferred phone numbers to contact you and whether or not our staff can leave detailed messages. Also use this form to list any person(s) with whom we may share details about your care, including billing information. Please indicate whether this may include sensitive health information (SHI) such as mental health, genetic testing, drug and/or alcohol abuse treatment, and sexually transmitted disease (STDs) including HIV/AIDS. Complete the below form to update your contact numbers.
Patient Amendment Requests
You have the right to request a change or amendment to your protected health information Duly Health and Care maintains in your medical record. To exercise your right to request an amendment, please complete the below form. *If you need to update your demographic information, please log in to MyChart or contact customer service at 866−734−7680.
Patient Requested Restriction
You have the right to request restrictions as to how your protected health information (PHI) may be used and/or disclosed to carry out payment. To exercise your right to request a restriction on the disclosure of your PHI, please complete the below form.
Care Everywhere Opt-Out
Duly Health and Care participates in Epic’s Care Everywhere to share your medical record via secure, encrypted connections. This enables your treating provider(s) to access your health information when you are receiving care outside of Duly Health and Care. This information shared includes your medical history, previous diagnoses, test results (i.e. labs and imaging), current medications, allergies, and progress notes. This connection allows for real-time access without having to wait for records to be transferred between facilities.
You may opt out if you do not want your record shared with your treating provider(s) through Care Everywhere. If you
opt out, you also have the right to opt back in at any time. To opt-out of Care Everywhere, please complete the below form.