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 (PHI). I understand that this information can and will be used to:

Conduct, plan and direct my child’s treatment and follow up among the multiple healthcare providers who may be involved in the treatment directly and indirectly.
Obtain payment from third party payers.
Conduct normal healthcare operations such as quality assessments and physician certifications.

I have read and understand the above information above. I also understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time to obtain a current copy of the Notice of Privacy Practices.

Guarantor’s initials:

I allow Caring Hands Children’s Clinic, LLC to provide complete copies of medical records for my child to any medical facility or person providing medical care to the patient.

Guarantor’s initials:

List any known individuals or medical facility you would like to have access to your child’s medical records:

Patient’s Name:

DOB:

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Guarantor’s Signature:

Date:

Practice Use Only

I attempted to obtain the patient’s signature in acknowledgement of the Notice of Privacy Practices, but was unable to do so because:

Employee’s Signature:

Date:

Your information will be encrypted.