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| PRIVACY NOTICE FOR GROUP VISITS |
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A group visit is a shared medical appointment where several patients, family, and friends meet with one provider at the same time.
During a group visit, some of your health information will no longer be private.
For example, at a group visit for diabetes others ar elikely to believe that you might have diabetes because you are in a diabetes group visit.
If you have medical concerns that you do not whant others to know about, you should discuss them with your doctor in a one-on-one appointment. |
• Group visits are not private. Conversations about your health or your health care during your group visits
are not private.
• You authorize discussion of your personal health information in a group setting.
• You may have a one-on-one appointment with your provider. You are not required to participate in a group visit.
• You voluntarily wish to participate in a group visit.
• You will respect the privacy of others in the group and will not talk about anyone else's health information
after the group visit is over.
• You will not hold Boice-Willis Clinic, PA, its employees , or officers responsible for any breach of confidentiality
committed by other participants in this group.
• Video or audio during group visits are not allowed.
• You are not required to sign this form to receive medical treatment.
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By signing this document, you agree that you have read and understand the statements listed above.
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Click to download: Notice of Privacy Practices (Revised 6/2018)
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By checking this box, I agree that my typed name will be considered the equivalent of my inked signature and I have downloaded a copy of the Notice of Privacy Practices. |
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Patient/Parent/Legal Guardian Name
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Electronic Signature
| Date
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