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Online registration
Messaging
Online billing
Free newsletter
24 hour access
HIPPAA Compliant
Appointment Scheduler
Patient Reminder
Added Value
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At Heartland, we are careful to comply with security standards set by industry. We maintain your records with
with the highest level of electronic and physical
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security. Occasionally, however, we must share your records with external entities (legal & medical).
Please read and agree with the below agreement to continue.
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| Welcome! Please read the directions and legal agreement below before you begin. |
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| By completing the registration packet herein, I hereby release all information
contained for use by the healthcare provider. I understand that the clinic will not sell my
information or share my information with other medical facilities without my
consent, except as described below. I understand that this information is to be used by the clinic
to assist in my medical well-being.
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| I have had full opportunity to read and consider the contents of this Authorization,
and I confirm that the contents are consistent with my direction to the healthcare provider.
I understand that, by clicking the Accept button below, I am confirming my authorization
that the health care provider may use and/or disclose to the persons and/or organizations named
in this form the protected health information described in this form.
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| Finally, I understand that I have the right to remove my records from the healthcare provider at
any time. If no such time is specified, the healthcare provider agrees to archive my records
one year after my last visit.
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