The health information
provided in the Self-Assessment Booklets and additional information obtained
during the Lions Club Health Fair
will be accessible only to the health professionals and Lions Club members
participating in the Health Fair.
Summary data used to educate Health Fair participants will have no
identifying information for specific individuals.
You have the right to:
·
Request restrictions on the uses and disclosures of
the health information
·
Inspect and obtain copies
·
Request amendments
·
Request an accounting of any disclosures
·
File a complaint about any violation of your privacy
rights with the United States Secretary of Health and Human Services
All specific
requests regarding your medical information should be in writing.
If
you would like a copy of the information gathered before and during the Health
Fair to be forwarded to your primary physician, please initial here.
_____
Please sign
below to acknowledge that you have read and understand this notice. Please contact the Lions Club Health Fair
coordinator if you have any questions.
I have read
and understand this notice regarding the privacy and use of the medical
information provided at the Lions Club Health Fair.
_________________________________
Signature
_________________________________
Name (please print)
_________________________________
Date