Notice of Privacy Practices & Patient Acknowledgement Form - HIPPA

I have received this practice’s Notice of Privacy Practices written in plain language. The Notice provides in detail the uses and disclosures of my protected health information that may be created by this practice, my individual rights and the practice’s legal duties with respect to my protected health information. The Notice includes:

1. A statement that this practice is required by law to maintain the privacy of protected health information.
2. A statement that this practice is abiding by the terms of notice currently in effect.
3. Types of uses and disclosures that this practice is permitted to make for each of the following purposes: treatment, payment, and health care operations.
4. A description of the other purposes for which this practice is permitted or required to use and/or disclose protected health information without my written consent or authorization.
5. A description of uses and disclosures that are prohibited or materially limited by law.
6. My individual rights with respect to protect health information and a brief description of how I may exercise these rights in relation to:

• The right to complain to this practice and to the Secretary of HHS if I believe my privacy rights have been violated, and that no retaliatory actions will be used against me in the event of such a complaint.
• The right to request restrictions on certain uses and disclosures of my protected health information, and that this practice is not required to agree to a requested restriction.
• The right to receive confidential communications of protected health information.
• The right to inspect and copy protected health information.
• The right to amend an accounting of disclosures of protected health information.
• The right to obtain a paper copy of the Notice of Privacy Practice upon request.

This practice reserves the right to change the terms of its Notice of Privacy Practices and to make new provisions effective for all protected health information that it maintains.

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.