Notice Of Privacy Practices Acknowledgement

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.

Please mark the boxes that we can contact you by

Home Email

Work Email

Cell Phone

Home Phone

Work Phone

All of the Above

Please name people who may have all or some of the chart info

All of info

Some of Info

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.

Patient Name / Signature

Relationship to patient

Date

Your information will be encrypted.