Release of Medical Information

Your private health information is strictly confidential and contains privileged medical information. To assure this confidentiality, information contained in your medical record will not be released to anyone, including your family members, without your written permission to do so. We recommend that pre-arrangements for the release of your medical information be discussed with your physician or our office staff. We require that you complete and sign the TPMG Notice of Privacy Practices Acknowledgement and Consent form which discloses who, if anyone, has your consent regarding your protected health information (PHI): (This form is commonly referred to as the HIPAA form). We may ask you to update and sign this form at every TPMG office, as you may not want some information in certain office specialties to be released as you may with other offices.

If you have advance directives such as an Advance Medical Directive or a Living Will, please provide us with a copy for inclusion in your private health information. It is your responsibility to help keep your private health information current. Please advise our staff of any changes in your name, address, telephone number or insurance carrier at the earliest opportunity. Also, we encourage patients to update their HIPAA form at least yearly to ensure the inclusion of children who reach adulthood and/or the addition or removal of names we can release information to due to marriage, death, separation, divorce, etc.

We will gladly provide copies of your private health information for referring physicians or other medical professionals who may need them to provide your care. Please allow at least 5 working days to process requests for medical records.

We reserve the right to charge for copying private health information, as well as for preparing disability forms, insurance applications, and other written documents relating to your diagnosis and treatment. All private health information including x-rays performed at our office remains the property of TPMG.

Authorization to Release Information Form:

Authorization to Release Medical Information