1601 N. Tucson Blvd. Suite 9
Tucson, AZ 85716-3450
Phone: (800) 635-1196
Hotline: (800) 419-4777
Association of American Physicians and Surgeons, Inc.
A Voice for Private Physicians Since 1943
Omnia pro aegroto


I, Dr. _________, hereby declare under penalty of perjury that the following is true and correct to the best of my knowledge, information, and belief:

1. I am a physician licensed to practice medicine in the State of _______. My field of specialty is _________. I am, or will soon be, electronically transmitting medical records.

2. The Privacy Rule directly and immediately injures my patients and me. Because the Rule applies to medical records created prior to enforcement, even paper records, my patient-physician communications are already affected. Their confidentiality is decreased due to the broad, warrantless access to medical records given to government by the Privacy Rule. The Rule already interferes with my duty to the Oath of Hippocrates ("I will not divulge [patient confidences], as reckoning that all such should be kept secret.").

3. The Privacy Rule's allowance of institutions permissively to share personal medical records has also harmed my relationship with my patients. As institutions gain access to my record-keeping about my patients, whether for payment purposes or to provide a second opinion, I can no longer rely on the traditionally high level of confidentiality protecting those records.

4. In addition, the Privacy Rule imposes substantial, immediate regulatory costs directly on my practice. The Privacy Rule requires me to incur significant expenditures for software, consultants, seminars and/or office training.

5. I am competent to testify to the matters stated herein.

Executed this day of __________ in the County of _______, State of ________: