HIPAA (Health Insurance Portability and Accountability Act)


What Information is HIPAA?

HIPAA stands for Health Insurance Portability and Accountability Act. It is a law designed to provide privacy standards to protect patients’ medical records or other health information provided to health plans, doctors, hospitals, and other health care providers.

What Information is protected?

Protected Health Information. All “individually identifiable health information” held or transmitted by a covered entity or its business associate, in any form or media, whether electronic, paper, or oral is considered protected health information.

Individually identifiable health information includes any information that identifies the individual or information that can reasonably be used to identify the individual, such as:

  • the individual’s past, present or future physical or mental health or condition,
  • the provision of health care to the individual, or
  • the past, present, or future payment for the provision of health care to the individual

Common identifiers include name, address, birth date, and/or Social Security Number.

General Principle for Uses and Disclosures

Basic Principle. A covered entity may not use or disclose protected health information except:

  • as the Privacy Rule permits or requires
  • as the individual who is the subject of the information (or the individual’s personal representative) authorizes in writing

Personal Representatives. A personal representative is a person legally authorized to make health care decisions on an individual’s behalf or to act for a deceased individual or the estate. In most cases, parents are the personal representatives for their minor children. Therefore, in most cases, parents can exercise individual rights, such as access to the medical record, on behalf of their minor children.

Required Disclosures. A covered entity must disclose protected health information in only two situations:

  • To the individual or personal representative when they request access to their protected health information or when they request an account of disclosure
  • To the department of human services for a compliance investigation or review or enforcement action


Authorized Uses and Disclosures

Authorization. A covered entity must obtain the individual’s written authorization for any use or disclosure of protected health information that is not for treatment, payment, or health care operations.

An authorization must be written in specific terms. It may allow use and disclosure of protected health information by the covered entity seeking the authorization, or by a third party.

All authorizations must be in plain language and contain specific information regarding the information to be disclosed or used, the person(s) disclosing and receiving the information, expiration, right to revoke in writing, and other data.

Restriction Request. Individuals have the right to request restricted use or disclosure of protected health information for treatment, payment or health care operations, disclosure to persons involved in the individual’s health care or payment for health care, or disclosure to notify family members or others about the individual’s general condition, location, or death.

A covered entity is under no obligation to agree to requests for restrictions. A covered entity that does agree must comply with the agreed restrictions, except for purposes of treating the individual in a medical emergency.

Access and Uses. For internal uses, a covered entity must develop and implement policies and procedures that restrict access and uses of protected health information based on the specific roles of the members of their workforce.

These policies and procedures must identify the persons, or classes of persons, in the workforce who need access to protected health information to carry out their duties, the categories of protected health information to which access is needed, and any conditions under which they need the information to do their jobs.

Disclosures and Requests for Disclosures. Covered entities must establish and implement policies and procedures (which may be standard protocols) for routine, recurring disclosures, or requests for disclosures, that limit the protected health information disclosed to that which is the minimum amount reasonably necessary to achieve the purpose of the disclosure.


Top Dog Solutions, LLC. policy, and procedure for processing requests for the release of medical records/protected health information is attached.







Our practice is dedicated to maintaining the privacy of your individually-identifiable health information (IIHI). In conducting our business, we will create and retain records regarding you and the treatment and services we provide to you. We are required by law to maintain the confidentiality of health information that identifies you. We also are required by law to provide you with this notice of our legal duties and the privacy practices that we maintain in our practice concerning your IIHI. By federal and state law, we must follow the terms of the notice of privacy practices that we have in effect at the time.



The terms of this notice apply to all records containing your individually-identifiable health information that are created or retained by our practice. We reserve the right to revise or amend this Notice of Privacy Practices. Any revision or amendment to this notice will be effective for all of your records that our practice has created or maintained in the past, and for any of your records that we may create or maintain in the future. Our practice will post a copy of our current Notice in our offices in a visible location at all times, and you may request a copy of our most current notice at any time.



Privacy Official at 4295 Interstate Drive Suite B Macon, Ga 31210               Phone: 800-239-1990



  1. TREATMENT. Our practice may use your IIHI to treat you. For example, we may ask you to have laboratory tests (such as blood or urine tests), and we may use the results to help us reach a diagnosis. We might use your IIHI in order to write a prescription for you, or we might disclose your IIHI to a pharmacy when we order a prescription for you. Many of the people who work for our practice – including, but not limited to, our doctors and nurses – may use or disclose your IIHI in order to treat you or to assist others in your treatment. Additionally, we may disclose your IIHI to others who may assist in your care, such as your spouse, children, or parents. Finally, we may also disclose your IIHI to other health care providers for purposes related to your treatment.
  2. PAYMENT. Our practice may use and disclose your IIHI in order to bill and collect payment for the services and items you may receive from us. For example, we may contact your health insurer to certify that you are eligible for benefits (and for what range of benefits), and we may provide your insurer with details regarding your treatment to determine if your insurer will cover or pay for your treatment. We also may use and disclose your IIHI to obtain payment from third parties that may be responsible for such costs, such as family members. Also, we may use your IIHI to bill directly for services and items. We may disclose your IIHI to other health care providers and entities to assist in their billing and collection efforts.
  3. LAWSUITS & SIMILAR PROCEEDINGS. Our practice may use and disclose your IIHI in response to a court or administrative order if you are involved in a lawsuit or similar proceeding. We also may disclose your IIHI in response to a discovery request, subpoena, or other lawful process by another party involved in the dispute, but only if we have made an effort to inform you of the request or to obtain an order protecting the information the party has requested.
  4. LAW ENFORCEMENT. We may release IIHI if asked to do so by a law enforcement official:
  • Regarding a crime victim in certain situations, if we are unable to obtain the person’s agreement
  • Concerning a death, we believe has resulted from criminal conduct
  • Regarding criminal conduct at our offices
  • In response to a warrant, summons, court order, subpoena, or similar legal process
  • To identify/locate a suspect, material witness, fugitive or missing person
  • In an emergency, to report a crime (including the location or victim(s) of the crime, or the description, identity, or location of the perpetrator)
  1. DECEASED PATIENTS. Our practice may release IIHI to a medical examiner or coroner to identify a deceased individual or to identify the cause of death. If necessary, we also may release information in order for funeral directors to perform their jobs.
  2. ORGAN & TISSUE DONATION. Our practice may release your IIHI to organizations that handle organ, eye, or tissue procurement or transplantation, including organ donation banks, as necessary to facilitate organ or tissue donation and transplantation if you are an organ donor.
  3. RESEARCH. Our practice may use and disclose your IIHI for research purposes in certain limited circumstances. Our practice may use your IIHI to determine whether you would qualify for research screenings and studies. We will obtain your written authorization to use your IIHI for research purposes except when an Institutional Review Board or Privacy Board has determined that the waiver of your authorization satisfies the following: (i) the use or disclosure involves no more than a minimal risk to your privacy based on the following: (A) an adequate plan to protect the identifiers from improper use and disclosure; (B) an adequate plan to destroy the identifiers at the earliest opportunity consistent with the research (unless there is a health or research justification for retaining the identifiers or such retention is otherwise required by law); and (C) adequate written assurances that the PHI will not be re-used or disclosed to any other person or entity (except as required by law) for authorized oversight of the research study, or for other research for which the use or disclosure would otherwise be permitted; (ii) the research could not practicably be conducted without the waiver; and (iii) the research could not practicably be conducted without access to and use of the PHI.
  4. SERIOUS THREATS TO HEALTH OR SAFETY. Our practice may use and disclose your IIHI when necessary to reduce or prevent a serious threat to your health and safety or the health and safety of another individual or the public. Under these circumstances, we will only make disclosures to a person or organization able to help prevent the threat.
  5. MILITARY. Our practice may disclose your IIHI if you are a member of U.S. or foreign military forces (including veterans) and if required by the appropriate authorities.
  6. NATIONAL SECURITY. Our practice may disclose your IIHI to federal officials for intelligence and national security activities authorized by law. We also may disclose your IIHI to federal officials in order to protect the President, other officials or foreign heads of state, or to conduct investigations.
  7. INMATES. Our practice may disclose your IIHI to correctional institutions or law enforcement officials if you are an inmate or under the custody of a law enforcement official. Disclosure for these purposes would be necessary: (a) for the institution to provide health care services to you, (b) for the safety and security of the institution, and/or (c) to protect your health and safety or the health and safety of other individuals.
  8. WORKER’S COMPENSATION. Our practice may release your IIHI for workers’ compensation and similar programs.



You have the following rights regarding your individually-identifiable health information (IIHI) that we maintain about you:

  1. CONFIDENTIAL COMMUNICATIONS. You have the right to request that our practice communicate with you about your health and related issues in a particular manner or at a certain location. For instance, you may ask that we contact you at home, rather than work. In order to request a type of confidential communication, you must make a written request to Privacy Official, 4295 Interstate Drive Suite B Macon, Ga 31210, specifying the requested method of contact, or the location where you wish to be contacted. Our practice will accommodate reasonable requests. You do not need to give a reason for your request.
  2. REQUESTING RESTRICTIONS. You have the right to request a restriction in our use or disclosure of your IIHI for treatment, payment or health care operations. Additionally, you have the right to request that we restrict our disclosure of your IIHI to only certain individuals involved in your care or the payment for your care, such as family members and friends. We are not required to agree to your request; however, if we do agree, we are bound by our agreement except when otherwise required by law, in emergencies, or when the information is necessary to treat you. In order to request a restriction in our use or disclosure of your IIHI, you must make your request in writing to Privacy Official, 4295 Interstate Drive Suite B Macon, Ga 31210. Your request must describe in a clear and concise fashion:

(a) the information you wish restricted;

(b) whether you are requesting to limit our practice’s use, disclosure or both; and

(c) to whom you want the limits to apply.

  1. INSPECTION & COPIES. You have the right to inspect and obtain a copy of the IIHI that may be used to make decisions about you, including patient medical records and billing records, but not including psychotherapy notes. You must submit your request in writing to Privacy Official, 4295 Interstate Drive Suite B Macon, Ga 31210 in order to inspect and/or obtain a copy of your IIHI.

Our practice may charge a fee for the costs of copying, mailing, labor and supplies associated with your request. Our practice may deny your request to inspect and/or copy in certain limited circumstances; however, you may request a review of our denial. Another licensed health care professional chosen by us will conduct reviews.

  1. AMENDMENT. You may ask us to amend your health information if you believe it is incorrect or incomplete, and you may request an amendment for as long as the information is kept by or for our practice. To request an amendment, your request must be made in writing and submitted to Privacy Official, 4295 Interstate Drive Suite B Macon, Ga 31210. You must provide us with a reason that supports your request for amendment. Our practice will deny your request if you fail to submit your request (and the reason supporting your request) in writing. Also, we may deny your request if you ask us to amend information that is in our opinion: (a) accurate and complete; (b) not part of the IIHI kept by or for the practice; (c) not part of the IIHI which you would be permitted to inspect and copy; or (d) not created by our practice, unless the individual or entity that created the information is not available to amend the information.
  2. ACCOUNTING OF DISCLOSURES. All of our patients have the right to request an “accounting of disclosures.” An “accounting of disclosures” is a list of certain non-routine disclosures our practice has made of your IIHI for non-treatment, non-payment or non-operations purposes. Use of your IIHI as part of the routine patient care in our practice is not required to be documented. For example, a doctor shares information with the nurse; or the billing department using your information to file your insurance claim. In order to obtain an accounting of disclosures, you must submit your request in writing to Privacy Official, 4295 Interstate Drive Suite B Macon, Ga 31210.

All requests for an “accounting of disclosures” must state a time period, which may not be longer than six (6) years from the date of disclosure and may not include dates before August 29, 2020. The first list you request within a 12-month period is free of charge, but our practice may charge you for additional lists within the same 12-month period. Our practice will notify you of the costs involved with additional requests, and you may withdraw your request before you incur any costs.

  1. RIGHT TO A HARDCOPY OF THIS NOTICE. You are entitled to receive a paper copy of our notice of privacy practices. You may ask us to give you a copy of this notice at any time. To obtain a paper copy of this notice, contact:

Privacy Official, 4295 Interstate Drive Suite B Macon, Ga 31210.   Phone: 800-239-1990


  1. RIGHT TO FILE A COMPLAINT. If you believe your privacy rights have been violated, you may file a complaint with our practice or with the Secretary of the Department of Health and Human Services. All complaints must be submitted in writing. You will not be penalized for filing a complaint. To file a complaint with our practice, contact:

Privacy Official, 4295 Interstate Drive Suite B Macon, Ga 31210.  Phone: 800-239-1990

. RIGHT TO PROVIDE AN AUTHORIZATION FOR OTHER USES & DISCLOSURES. Our practice will obtain your written authorization for uses and disclosures that are not identified by this notice or permitted by applicable law. Any authorization you provide to us regarding the use and disclosure of your IIHI may be revoked at any time in writing. After you revoke your authorization, we will no longer use or disclose your IIHI for the reasons described in the authorization. Please note we are required to retain records of your care.

  1. RIGHT TO OPT-OUT OF THE USE OF SECURED ELECTRONIC DEVICES OF YOUR IIHI. Our practice may require the use of electronic devices such as e-mail and text to send secured messages for correspondence of your individually-identifiable health information for treatment, payment or health care operations. If you would like to opt-out of using secured electronic devices to communicate please contact, in writing: Privacy Official, 4295 Interstate Drive Suite B Macon, Ga 31210. Phone: 800-239-1990





The following categories describe unique scenarios in which we may use and/or disclose your identifiable health information:

  1. PUBLIC HEALTH RISKS. Our practice may disclose your IIHI to public health authorities that are authorized by law to collect information for the purpose of:
  • Maintaining vital records, such as births and deaths
  • Reporting child abuse or neglect
  • Preventing or controlling disease, injury or disability
  • Notifying a person regarding potential exposure to a communicable disease
  • Notifying a person regarding a potential risk for spreading or contracting a disease or condition
  • Reporting reactions to drugs or problems with products or devices
  • Notifying individuals if a product or device they may be using has been recalled
  • Notifying appropriate government agencies and authorities regarding the potential abuse or neglect of an adult patient (including domestic violence); however, we will only disclose this information if the patient agrees or we are required or authorized by law to disclose this information
  • Notifying your employer under limited circumstances related primarily to workplace injury or illness or medical surveillance.
  1. HEALTH OVERSIGHT ACTIVITIES. Our practice may disclose your IIHI to a health oversight agency for activities authorized by law. Oversight activities can include, for example, investigations, inspections, audits, surveys, licensure and disciplinary actions; civil, administrative, and criminal procedures or actions; or other activities necessary for the government to monitor government programs, compliance with civil rights laws and the health care system in general.
  2. HEALTHCARE OPERATIONS. Our practice may use and disclose your IIHI to operate our business. As examples of the ways in which we may use and disclose your information for our operations, our practice may use your IIHI to evaluate the quality of care you received from us, or to conduct cost-management and business planning activities for our practice. We may disclose your IIHI to other health care providers and entities to assist in their health care operations.
  3. APPOINTMENT REMINDERS, BILLING ACTIVITIES, LABORATORY & DIAGNOSTIC TEST RESULTS. Our practice may use and disclose your IIHI to contact you and remind you of an appointment and to discuss billing activities and laboratory and diagnostic test results. Our practice may use electronic devices to communicate such information.
  4. TREATMENT OPTIONS. Our practice may use and disclose your IIHI to inform you of potential treatment options or alternatives.
  5. HEALTH-RELATED BENEFITS & SERVICES. Our practice may use and disclose your IIHI to inform you of health-related benefits or services that may be of interest to you.
  6. RELEASE OF INFORMATION TO FAMILY/FRIENDS. Our practice may release your IIHI to a friend or family member that is involved in your care, or who assists in taking care of you. For example, a parent or guardian may ask that a babysitter take their child to the pediatrician’s office for treatment of a cold. In this example, the babysitter may have access to this child’s medical information.
  7. DISCLOSURES REQUIRED BY LAW. Our practice will use and disclose your IIHI when we are required to do so by federal, state or local law.
  8. PATIENT SATISFACTION SURVEYS. Our practice may use your IIHI to periodically send you Patient Satisfaction Surveys unless you instruct us not to. Our practice contracts with an external survey company to conduct the surveys and provide our practice with the results.




Telemedicine involves the use of electronic communications to enable health care providers at different locations to share individual patient medical information for the purpose of improving patient care. Providers may include primary care practitioners, specialists, and/or subspecialists. The information may be used for diagnosis, therapy, follow-up and/or education, and may include any of the following:

  • Patient medical records
  • Medical images
  • Live two-way audio and video
  • Output data from medical devices and sound and video files

Electronic systems used will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.



  • Improved access to medical care by enabling a patient to remain in his/her office (or at a remote site) while the physician obtains test results and consults from healthcare practitioners at distant/other sites.
  • More efficient medical evaluation and management.
  • Obtaining expertise of a distant specialist.



As with any medical procedure, there are potential risks associated with the use of telemedicine. These risks include, but may not be limited to:

  • In rare cases, information transmitted may not be sufficient (e.g. poor resolution of images) to allow for appropriate medical decision making by the physician and consultant(s);
  • Delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment;
  • In very rare instances, security protocols could fail, causing a breach of privacy of personal medical information;
  • In rare cases, a lack of access to complete medical records may result in adverse drug interactions or allergic reactions, or other judgment errors.




  1. I understand that the laws that protect privacy and the confidentiality of medical information also apply to telemedicine, and that no information obtained in the use of telemedicine which identifies me will be disclosed to researchers or other entities without my consent,
  2. I understand that I have the right to withhold or withdraw my consent to the use of telemedicine in the course of my care at any time, without affecting my right to future care or treatment,
  3. I understand that I have the right to inspect all information obtained and recorded in the course of telemedicine interaction, and may receive copies of this information for a reasonable fee,
  4. I understand that a variety of alternative methods of medical care may be available to me, and that I may choose one or more of these at any time. (name of Physician) has explained the alternatives to my satisfaction,
  5. I understand that telemedicine may involve electronic communication of my personal medical information to other medical practitioners who may be located in other areas, including out of state.
  6. I understand that it is my duty to inform (name of Physician) of electronic interactions regarding my care that I may have with other healthcare providers.
  7. I understand that I may expect the anticipated benefits from the use of telemedicine in my care, but that no results can be guaranteed or assured.
  8. I attest that I am located in the state of California and will be present in the state of California during all telehealth encounters with (name of Physician).



I have read and understood the information provided above regarding telemedicine, have discussed it with my physician or such assistants as may be designated, and all of my questions have been answered to my satisfaction. I hereby give my informed consent for the use of telemedicine in my medical care.

I understand a copy of this form will be available for me to print.

I hereby authorize Top Dog Solutions to use telemedicine in the course of my diagnosis and treatment.


Financial Responsibility

Please note: All health plans are not the same and do not cover the same services. In the event your health plan determines a service to be “not covered” or you do not have authorization, you will be responsible for the complete charge.  If you do not want results reported via telemedicine this should be expressed at the time of the schedule telemedicine appointment confirmation.

Accounts cannot carry balances longer than 60 days; regardless if insurance payment is still pending.  If the insurance company does not pay the practice within 60 days, we will look to the responsible party for payment.

Self-Pay costs are the upfront cost and based on the specific service provided.

COVID-19 testing, Pandemic, and HRSA uninsured program.  On March 18, 2020, the president signed the Families First Coronavirus Response Act. To facilitate the identification of patients with coronavirus disease 2019 (COVID-19), the act requires most insurers to eliminate cost-sharing for COVID-19 testing and for health care visits during which COVID-19 testing is ordered. Additionally, the act gives states the option to fully cover these costs for uninsured patients. These provisions will provide important financial protections to some patients who seek evaluation because they were exposed to COVID-19, have concerning symptoms, or both. However, patients still can be financially liable depending on the nature of the evaluation and the type of health insurance they have.

Insurance cards

You must bring your current insurance card to every visit.

Insurance Filing

As a courtesy to all of our patients, we will file insurance claims.  Your insurance is a contract between you and the insurance company and we are not a party to this contract.  We have no control over the terms of your contract, the method of reimbursement or the determination of benefits.  Any disputes with insurance companies overpayments or lack thereof are the responsibility of the insured.

If your insurance company requires authorization, it is your responsibility to make sure we have that authorization prior to the visit or service.

Only uninsured patients are allowed to use the HRSA uninsured program (free testing).  The insured patients are attesting to a truthful statement and submission of insurance information and demographics to Top Dog Solutions, LLC.


We understand that emergencies happen. Please call or cancel your appointment online 24 hours in advance.  If you arrive 15 minutes after your appointment time we will try to work you in, but at times we will be required to reschedule your appointment.

Signing this form is a written acknowledgment to having the opportunity to review a copy of all material listed above (HIPAA, Telemedicine, HRSA attestation, Patient responsibility, and Top Dog Policies) for Top Dog Solutions, LLC.