Statement of Patient / Customer Privacy
The following Privacy Statement sets forth the protection of information related to the services and/or product(s) you may request. To provide services and/or fill your requested order, you verify that you have read and understand these conditions.
As part of the processing of your order through Patient Health Services, you will be asked to provide certain individually identifiable personal information, including your name, email and mailing address, telephone number, billing information (including your credit card number or checking account information), in addition to other information to facilitate the ordering, billing, or payment process. This information is maintained in a secure encrypted form and is not given, sold, traded, or otherwise provided to third parties unless legally required. Individually identifiable health information provided on the Medical History Form or as a part of any medical consultation will not be released other than to the prescribing physician and the pharmacy or to the subscriber or the subscriber’s authorized representatives or designated agent.
Patient Health Services will have continuing access to and the right to copy and retain any and all portions of my medical records and information.
Your IP address is logged and may be used to administer our website and diagnose any problems with our server, or prevent fraud.
We may also use the information you provide us to send you information about your order, additional information about the site, or information about special offers or products through us or our affiliated companies that you might be interested in receiving, unless you request not to receive such information. Our site uses “cookies” to help us identify you as a prior customer, retrieve information you provided previously, and otherwise personalize your interaction with our site. You should refer to your browser instructions or help menu if you would like information on whether your browser enables you to block cookies, receive a warning before a cookie is stored, or remove cookies from your computer’s hard drive.
If you need to update, modify, or change your information in our database or if you choose to opt-out of receiving future communications from us contact us by email at email@example.com
Patient Authorization for Release of Individually Identifiable Health Information
In connection with providing certain individually identifiable health information to Patient Health Services, I authorize the following:
I hereby authorize Patient Health Services to use and disclose any of my health information, including all individually identifiable health information contained in the Health Information Form for the purpose of treatment, payment and health care operations. This authorization additionally includes, but is not limited to, any health information relating to HIV and other sexually transmitted diseases, mental health or disease, drug or alcohol treatments.
Patient Health Services’s terms and conditions provide detailed information about working with us, and you are asked to review it before agreeing to proceed.
I declare under penalty of perjury that the foregoing is true and correct. My agreement to this statement constitutes my signature.