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HIPAA Department

Available Forms and Links

Radiology Ltd. Notice of Privacy Practices (Printable Version)

Aviso de Prácticas de Privacidad (Versión para imprimir)
Our Notice of Privacy Practices describes how medical information about you may be used and disclosed, how you can get access to this information, and your rights as a patient under HIPAA.

Alternative Manner and Method of Confidential Communication Form
You may request that your health information be communicated to you via alternative methods. We will normally communicate with you by home phone and mailing address. Radiology Ltd. reserves the right to deny any request considered unreasonable.

Alternate Manner & Method of Confidential Communication Revocation Form
You may request to revoke a previously filed alternate form of communication.

Protected Health Information Authorization Form
Designate an individual other than yourself to receive your health care information. Be sure to specify what information you would like them to have access to (make/change appointments, receive reports, etc.).

General Authorization Revocation Form
Revoke a previously filed authorization for a specific individual or entity prior to the designated expiration date.

Request to Restrict the Use & Disclosure of Protected Health Information Form
You may request to restrict the Use & Disclosure of your protected health information from an individual or entity who would not normally require your authorization to receive this information (health insurance provider, healthcare provider, etc.). Radiology Ltd. has the option to accept or deny your written request.

Request to Restrict the Disclosure of Protected Health Information to your Healthcare Insurance Provider
Radiology Ltd. is required to accept your request to restrict PHI access from your insurance provider once your request is made in writing and you pay in full at the time of your exam.

Restriction Revocation Form
Revoke a previously requested Restriction.

Request to Correct or Amend Health Information
Request a correction or amendment to your existing health information.

Request for an Accounting of Disclosures
You may request to receive a written record of certain disclosures we have made of your protected health information during the last 6 years. If you ask for this information from us more than once every 12 months we may charge you a fee.

Medical Record Release of Health Information Authorization Form
Allow Radiology Ltd. to obtain any or all of your outside medical records for the purpose of comparison and/or assisting in the interpretation of your procedure.

Additional Resources

How to File a HIPAA Privacy/Security Complaint

Please use the form below to contact our HIPAA and Security Department with any questions or concerns you may have, or to submit documentation to this group.

Privacy Officer
Phone: 844-754-1507
Fax: 704-941-3464



Understanding Health Information Privacy

The HIPAA Privacy Rule provides federal protections for personal health information held by covered entities and gives patients an array of rights with respect to that information. At the same time, the Privacy Rule is balanced so that it permits the disclosure of personal health information needed for patient care and other important purposes.

Learn more at

How to File a Complaint with the Office of Civil Rights

If you believe that a covered entity violated your (or someone else’s) health information privacy rights or committed another violation of the Privacy or Security Rule, you may file a complaint with the Office for Civil Rights.

What to expect