Notice of Privacy PracticesAdministrator2020-12-17T10:52:12-05:00

Notice of Privacy Practices

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View Notice of Privacy Practices PDF

Acknowledgement:*
- I understand that, under the Health Insurance Portability & Accountability Act of 1996 (“HIPPA”), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:
  - • Conduct, plan, and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly.
  - • Obtain payment from third-party payers.
  - • Conduct normal healthcare operations such as quality assessments and physician certifications.
  I have received, read and understand your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I understand that this organization has the right to change it Notice of Privacy practices from time to time and that I may contact this organization at any time at the address above to obtain a current copy of the Notice of Private Practices.
  I understand that I may request in writing that you restrict how my private information is used or Disclosed to carry out treatment, payment or health care operations. I also understand you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions.
Signature
Patient Name:*
Relationship to Patient:*
Signature:*
Date*
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