Notice Of Privacy Practices Acknowledgement

Please correct the errors described below.

I understand that under the health insurance portability and 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 or indirectly
  • Obtain payment from third-party payers.
  • Conduct normal healthcare operations such as reminders of appointments for continuing or follow up care.

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.

Your information will be encrypted.

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