Page 7 - Forms - New Patient Paperwork (Dec-2017)_Neat

HEALTH INFORMATION PRIVACY AGREEMENT
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The Swan Center for Plastic Surgery and its physicians and staff are dedicated to protecting the privacy of
(Patient Name). We understand the physician-patient relationship is
built on trust, patients are able to share important and sensitive information confidently and freely with
their physicians, which results in better care. We are sensitive to the issues involving the confidentiality
of medical information maintained in electronic form and have implemented careful practices to protect
the privacy of such information. While the practice is required by law to maintain the privacy of
protected health information, we take pride in extending an even greater degree of privacy than the law
requires. In addition, regardless of legal privacy loopholes, the practice will never attempt to leverage its
relationship with the patient by seeking consent for marketing products for others.

In consideration for treatment, the above noted patient protection, and the practice’s mutual promise
below, the patient agrees to refrain from directly or indirectly publishing or airing any commentary on the
practice (including Joseph G. Bauer, M.D., Dean J. Fardo, M.D., Cristen M. Catignani, M.D. and all
employees of The Swan Center for Plastic Surgery) or on the expertise and/or treatment of its physicians
or staff. Publishing is intended to include attribution by name, by pseudonym, or anonymously. The
patient acknowledges that published comments on web pages or blogs, through mass correspondence, or
by other means, however well-intended, could severely damage the practice, which has invested
significant financial and marketing resources to establish its reputation. The sole exceptions to this
prohibition are that the Patient may make such communications to a confidential medical-peer review
body; to another healthcare provider; to a licensed attorney; to a governmental agency; as part of a legal
proceeding; or if mandated by law. If the patient does prepare commentary for publication about the
practice (other than for the permitted recipients specifically identified in the preceding sentence), the
patient exclusively assigns all intellectual property rights, including copyrights, to the practice for any
written, pictorial, and/or electronic commentary. This assignment is in further consideration for
additional privacy protections provided by the practice. This assignment shall be operative and effective
at the time of creation (prior to publication) of the commentary. In addition, the patient will not denigrate,
defame, disparage, or cast aspersions upon the practice; and will use all reasonable efforts to prevent
any member of his/her immediate family or acquaintance from engaging in any such activity.

The Swan Center for Plastic Surgery feels strongly about the patient’s privacy, as well as the practice’s
right to control its public image and privacy. Therefore, both the practice and the patient will work to
prevent the publishing or airing of commentary about the other party from being accessed via
internet, blogs, or other electronic, print, and/or broadcast media without prior written consent.
Finally, this Agreement shall be enforceable, and fully survive, for a period of the longer of: (a) five
years from the practice’s last date of service to the patient; or (b) three years beyond any termination of
the physician-patient relationship.

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