Notice of privacy practices

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Patient Name: __________________________________________ DOB: _____/_____/________


Bala Family Practice has implemented the following policies and procedures so that the confidentiality of your personal and/or medical information remains confidential.Your physician(s) and all other employees working in Bala Family Practice will keep any information related to you (medical and/or non-medical) in a confidential manner. However, so that we may provide you with appropriate medical care, for general practice operations and/or for the purposes of obtaining payment, we will, at our discretion provide information pertaining to the treatment you received in this practice, file charges for this treatment and supply related information regarding the treatment and charges to other health care related entities. This information will be submitted through the following mechanisms: US Postal Service, fax transmission, Internet transmission, voice and/or personal communications. The following is a list of the most common types of entities that we most typically would provide personal health related information. This list is not an all-inclusive list. Other entities may be added to this list at our discretion.

  • Physician and non-physician providers (ie. Specialty therapist, counselors, school health departments) who work outside of this practice.

  • Medical facilities (ie. Hospitals, outpatient centers).

  • Laboratories for the purposes of running medical tests.

  • Other healthcare providers, such a pharmacies regarding prescription medications, durable medical equipment suppliers and ambulance services.

  • Insurance companies (or third party administrators) for the purpose of obtaining, reviewing medical necessity and/or general case management.

  • State or Federal Agencies that require the submission of specific health related information.

We may need to contact you, by phone, to discuss or confirm your appointments, test results, treatments, referrals, account balance and/or return your phone call. We will first attempt to contact you on your home and/or cell phone numbers, however, if you are not available at these numbers and have provided a work number, we will attempt to contact you at work. If you are not available, we will leave a message for you either on your home phone, cell phone or work phone to either call Bala Family Practice or remind you of your appointment time. These messages are sometimes left on personal message devices, such as an answering machine. If you do not want messages left on machines for you, please give us this information in writing.

We have chosen to participate in the Chesapeake Regional Information System for our Patients (CRISP), a regional health information exchange serving Maryland and D.C. As permitted by law, your health information will be shared with this exchange in order to provide faster access, better coordination of care and assist providers and public health officials in making more informed decisions. You may “opt-out” and disable access to your health information available through CRISP by calling 1-877-952-7477 or completing and submitting an Opt-Out form to CRISP by mail, fax or through their website at Public health reporting and Controlled Dangerous Substances information, as part of the Maryland Prescription Drug Monitoring Program (PDMP), will still be available to providers.


Bala Family Practice will use your health related information for the purposes of providing you with medical treatment, obtaining payment for service rendered and/or for general health care operations. Your health related information will be submitted through the following mechanisms: US Postal Service, fax transmission, Internet transmission, voice and/or personal communications. The most common entities that will receive this information are: other providers, facilities, insurance companies and pharmacies. More specific information pertaining to our practice policies is provided for you in the Notice of Privacy Practices shown above. Please review prior to signing this consent. The terms of our Notice of Privacy Practices may change at any time. You may contact the office and request a revised policy. Also, if you so choose, you may request that we restrict the use of your health information for purpose of treatment, payment and/or health care operations. We are not required to agree with your requested restrictions. In the event we do agree with your restrictions, we will adhere to these restrictions. If we do not agree with your request, we will discontinue treatment.

I have read the Notice of Privacy Practices shown above. _____________ (Initial)

I understand that I may revoke, at any time, this consent. This revocation will not affect previous actions, prior to the revocation. ___________(Initial)

I consent to the above terms related to the use and disclosure of my individually identifiable health information for the purposes of treatment, payment and/or health care operations. I understand this will remain in effect until I revoke it, in writing.

Patient Name (Print) _____________________________________ Signature ________________________________ Date _____/_____/______

Bala Family Practice will I have read the provided Privacy Practices information shown above which contains a Health Insurance Portability and Accountability Act of 1996 (HIPAA). I hereby authorize Bala Family Practice to release any information necessary for my course of treatment. I also authorize the release of medical information to anyone to which they may release billing and patient care information on a regular basis. In addition, I hereby authorize the release of information to personal acquaintance named below (and relationship if possible).

1) _______________________________________________________ Relationship: ________________________________________

2) _______________________________________________________ Relationship: ________________________________________

I have read the provided policy regarding my financial responsibility to Bala Family Practice (located on the Bala Family Practice website) for providing service to the above named patient or me. I certify that the information provided is so, to the best of my knowledge, true and accurate. I authorize my insurer to pay any benefits directly to Bala Family Practice. I agree to pay Bala Family Practice the full and entire amount of all bills incurred by me or the above named patient, if applicable, or any amount due after payment has been made by my insurance carrier.

Patient Name (Print) _____________________________________ Signature ________________________________ Date _____/_____/______
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