Patient Privacy Policy

In order to protect sensitive personal and medical information, we have instituted a number of measures aimed at maintaining your privacy. The National Institutes of Health have newly developed Health Information Privacy Act (HIPA) that requires every medical provider to make available to patients a privacy policy. This effort is to maintain privacy of patient in formation in an era of high technology and data-laden medical systems. The end result will be a more streamlined system of medical information with a higher degree of information security in the process. The following is the policy for patients in this office regarding patient privacy and confidentiality of information collected and stored in this office:

  • Payments and Scheduling will be done by the office manager (or the doctors). Patients must remain in the waiting area and NOT at the office manager’s desk so that the schedule book and computer screen are NOT visible to them.
  • An information sheet with demographic data, insurance information, consents for treatment, and medical disclosure will be completed by every patient as part of her/his record. A copy of this sheet and the insurance card(s) will be released to our office manager for billing records and to help process medical claims. This form will include the patient’s preferences for where appointment reminders may be left, (home, work or cell phone.)
  • All superbills for office visits will be shared with the office manager in order to process insurance claims and record business transactions for tax purposes.
  • Any paper trash with patient information will be shredded prior to discarding it.
  • Employees and staff are required to sign a confidentiality agreement regarding any information they are exposed to in the office setting which is not to be discussed or revealed to any person(s)/business(es) outside of the office setting without prior written consent by the patient/legal guardian.
  • Medical release forms are required to be signed by the individual or parent/guardian in order to release any medical information to themselves, medical offices, insurance companies, or to any other desired location. A copying charge may apply for extensive record copying.
  • Only first names will be used when addressing patients in the office.
  • All medical related conversations will occur in private.
  • All papers related to patient care will be stored in cabinets when not in use where only authorized medical staff has access to them.


Any breech of confidentiality must be submitted in writing to Dr. Pelkey for proper action to be taken to amend the situation and/or policy.