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  • HIPPA Notice of Privacy Practices

    This notice was published and becomes effective on April 14th 2003

    Women to Women, Dr. Valerie A. Knudsen, M.D. 2831 Fort Missoula Road, Suite 306 Missoula, MT 59804 406-327-4395

    THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

    Uses and disclosures of Protected Health Information: Your protected health information may be used and disclosed by your physician, our office staff and others outside of our office that are involved in you care and treatment for the purpose of providing healthcare services to you, to pay your healthcare bills, to support the operation of the physician's practice and any other use requires by law.

    Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your healthcare and any related services. This includes the coordination or management of your health care with a third party.

    Payment: Your protected health information will be used, as needed, to obtain payment for your healthcare services.

    Healthcare Operations: We may use or disclose, as needed, your protected health information in order to support the business issues as required by law, Communicable Diseases, Health Oversight, Abuse or Neglect, Food and Drug Administration requirements, Legal Proceedings, Law Enforcement, Coroners, Funeral Directors, Organ Donation, Research, Criminal Activity, Military Activity, National Security, Worker's Compensation, and Inmates.

    Required Uses and Disclosures: Under the law we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of Section 164.500. Other permitted and required uses and disclosures will be made only with your consent, authorization or opportunity to object unless required by law. You may revoke this authorization at any time, in writing except to the extent that you physician or the physician's practice has taken an action in reliance on the use or disclosure indicated in the authorization.

    • You have the right to inspect and copy your protected health information. Under federal law, however, you may not inspect or copy the following records: psychotherapy notes, information compiled in reasonable anticipation of or use in a civil, criminal or administrative action or proceeding and protected health information that is subject to law that prohibits access to protected health information.

    • You have the right to request a restriction of your protected health information. Your physician is not required to agree to a restriction that you may request. If your physician believes it is in your best interest to permit use and disclosure of your protected health information, your protected health information will not be restricted. You then have the right to use another healthcare professional.

    • You have the right to request or receive confidential communications from us by alternative means or at an alternative location. You have the right to obtain a paper copy of the notice from us.

    • You may have the right to have your physician amend your protected health information.

    • You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information.

    Complaints: You may complain to us or the secretary of Health and Human Services if you believe your privacy rights have been violated by us.

    We will not retaliate against you for filing a complaint.

    By clicking Next you are providing your acknowledgment that you have received and understand this Notice of our Privacy Practices:

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Patient Forms

Instructions:

  1. Please click each link below to download the required forms for your appointment and print them off.

  2. Please read each document thoroughly and complete to the best of your ability.

  3. Please bring the filled out forms with you for faster service at your appointment.

    These forms are required and include specific instructions, please fill and review all information carefully. If you have any questions please feel free to either use our online contact form or give us a call at: (406) 327-4395

 

  • Personal Information and HIPPA Notice of Privacy Practices:

    • Please fill out this form (FRONT & BACK) to the best of your ability then sign the bottom of the front and back. The back of this form describes how medical information about you may be used by our office and/or a third party as well as giving our office permission to share your info with said parties.
  • Financial Agreement:

    • Please carefully read the front and back of this form then sign on the line at the bottom. This is an explanation of your responsibility as our patient to update your information, ensure your financial cooperation and general expectations we have for our patient clientele. By signing, you agree to uphold our policies.
  • Contact Information:

    • Please give any and all contact information possible, indicate your preferred contact and whether we are allowed to leave a message at any of these possible forms of contact.
  • Insurance Agreement:

    • Please read this form carefully as it concerns and explains our protocol for payment before and after ALL appointments. Initial next to one of the two options that applies personally to you then sign and date the bottom line.
  • Patient & Family History:

    • Please fill out both of these forms (FRONT & BACK) to the best of your ability and list any additional questions or concerns at the bottom of the last page.
  • Cancer Risk Assessment:

    • ONLY patients at risk for cancer need to fill out this form. If applicable, please fill out this form to the best of your ability, the doctor will review it with you during your appointment.

Thank you so much for completing all of our paper work to the best of your ability, we do understand this isn’t the most fun and your time is very valuable to us, we do truly appreciate it.  Please return all paperwork to reception when it is completed, thank you!!!

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