NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT

Please correct the errors described below.

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.

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.

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.

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