RELEASE OF CONFIDENTIAL INFORMATION

This disclosure pertains to HIPAA – The Health Insurance Portability and Accountability Act of 1996, also known as Kennedy-KassebaumAct. HIPAA calls for, among other things, security standards protecting the confidentiality and integrity of “individually identifiable health information,” past, present and future. Your medical records will be kept confidential and only you the patient will have access to them, except in certain circumstances, for example for billing purposes, your insurance company may request your records in order to clear a claim. When you signed with your insurance company you already signed for the release of relevant records if necessary. Also, when you need authorization from your insurance company to see a specialist, your insurance company may request a copy of your records. In order to continue your care through a specialist, we may fax or mail or give verbal knowledge of your medical history to the specialist. A copy of the “Notice of Privacy Practices” is enclosed in this document for your review.

Deepa B Verma, MD, ABIHM

3165 N. McMullen Booth Rd, D-2

Clearwater, FL 33761

(p) 727.754.2936 (f) 727.754.2937

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