Northeast Surgical Group’s Notice of HIPAA Privacy Practices is available via the attached file. 

NESG Notice of Privacy Practices – READ, don’t print (6 Pages)

For release of a patient’s protected health information, one of the following documents would be required, based on the circumstances.  Please call our office for additional information.

For release of records to the patient for their own use, the following form is required.  Please note that a fee for processing may be required.  All sections of the form must be completed or it may be returned.

NESG Request to Inspect AND – OR Copy PHI (1 page)

For release of records to a third party (e.g. another physician, social security, etc.), the following form is required.  Please note that a fee for processing may be required.  All sections of the form must be completed or it may be returned.

NESG Authorization for Use of PHI (2 pages)

For completion of an ATTENDING PHYSICIAN STATEMENT, DISABILITY FORM OR FMLA FORM, the following packet of information is required. Please note that a fee for processing may be required.  All sections of the form must be completed or it may be returned.

DISABILITY AND FMLA FORM guidelines, PHI disc and auth form for patient (3 pages)