• Notice of Privacy Practices Acknowledgement


    I understand that, under the Health Insurance Portability & Accountability Act of 1996 (“HIPAA”), 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 assessments.
    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