About NPS’s Patient Privacy in Henderson & Las Vegas, NV

Patient Notice of Privacy Practices and Consent Form

This notice of Privacy Practices provides information about how Nevada Pediatric Specialists may use and disclose protected health information about you. The Notice contains a Patient Rights section describing your rights under the law. You have the right to review this Notice before signing this Consent. We have the right to revise this notice at any time but will advise you of any major changes.

You have the right to request that we restrict how protected health information about you is used or disclosed for treatment, payment, or health care operations. We are not required to agree to this restriction, but if we do, we shall honor that agreement unless we are obligated to provide this information as required by law.

By signing this form, you consent to our use and disclosure of protected health information for treatment purposes, obtaining payment for our services, and healthcare operations. You have the right to revoke this consent, but it must be in writing and signed. However, such revocation shall not affect any disclosures already made prior to the date of your recission. The practice provides this form to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

The patient/guardian understands that:

• Protected health information may be used or disclosed for treatment, payment, or operations. The patient may request restrictions, but Nevada Pediatric Specialists is not required to agree.
• Nevada Pediatric Specialists participates in a secure Health Information Exchange (HIE). You may opt out at any time by completing an Opt-Out Form. If you do, we will not upload your information, though providers may still see information already in the HIE.
• Nevada Pediatric Specialists has a Notice of Privacy Practices, and the patient has the opportunity to review this notice.
• Nevada Pediatric Specialists reserves the right to change the Notice of Privacy Practices.
• The patient may revoke this Consent in writing at any time, and all future disclosures will then cease, unless required by law.
• Nevada Pediatric Specialists may continue treatment upon the execution of this consent.

By signing with my finger, stylus, or other electronic methods, I acknowledge that this electronic signature is my act and has the same legal effect as a handwritten signature. I consent to use electronic records and signatures in place of paper documents and handwritten signatures for all purposes in this transaction.

3201 S. Maryland Parkway, Suite 608
Las Vegas, NV 89109

880 Seven Hills Drive, Suite 100
Henderson, NV 89052

Telephone: 702.457.5437
Fax: 702.464.5801
www.nvpeds.com