Privacy Policy, Terms, and Conditions

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE AND CONSENT TO USE, RETRIEVE AND DISCLOSE HEALTH INFORMATION

Read before signing the Acknowledgement and Consent

This acknowledgement of notice and consent authorizes Chertow Orthopaedic & Sport Medicine to use and disclose health information about you for treatment, payment, and health care operations purposes.

Notice of Privacy Practices. Chertow Orthopaedic & Sport Medicine has a Notice of Privacy Practices, which describes how we may use and disclose your protected health information and how you can access your protected health information and exercise other rights concerning your protected health information. You may review our current notice prior to signing this acknowledgement and consent.

Amendments: We reserve the right to change our Notice of Privacy Practices and to make the terms of any change effective for all protected health information that we maintain, including information created or obtained prior to the date of the effective date of the change. You may obtain a revised notice by submitting a written request to our Privacy Officer.

Terms and Conditions:

By Texting the office at 833-372-6637 you are waiving your HIPAA rights and agree to communicate via a toll free number. By calling or texting you agree to receive text messages. If you no longer wish to receive text messages, you may opt-out at any time by replying with the word "STOP". 

How to contact our Privacy Officer:

Chertow Orthopedic & Sports Medicine

Attention: Private Officer

PO BOX 505

HORSHAM, PA 19044

Telephone/Fax (833) 372-6637

Acknowledge and Consent: I have received the Notice of Privacy Practices for Chertow Orthopaedics & Sports Medicine. Chertow Orthopaedic & Sport Medicine is authorized to use and disclose health information about you (the patient) for treatment, payment, and healthcare operations purposes consistent with the Notice of Privacy Practices.

Medication History: I agree that Chertow Orthopaedics & Sports Medicine may request and use my prescription medication history from other healthcare providers or third party pharmacy benefit payors for treatment purposes.