All information that is obtained from you by this office is protected and kept confidential. Every reasonable measure to prevent unauthorized disclosure of your protected health information is practiced.
Your protected health information can be disclosed without your written authorization in certain limited circumstances,
For any purpose other than treatment, obtaining payment, healthcare operations, or certain circumstances, we will ask for your written authorizations before using or disclosing your protected health information. If you choose to sign an authorization to disclose protected health information, you can revoke that authorization in writing at any time.
*Conditions and limitations may apply; obtain additional information from the front desk.
Changes To This Notice: We reserve the right to change privacy practices and the conditions of this notice at any time and without prior notice. In the event of changes, an update notice will be posted and a copy will be sent to you.
This document acknowledges that you have received a copy of the Notice of Privacy Practices. This document is not a contract, authorization, release, Or consent form. This document will remain in your records.
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If the patient is a minor, a parent of legal guardian must sign.
acknowledge that I have received a copy of the Notice of Privacy Practices
If the patient is not a minor but under the care of a relative, friend, or caregiver, sign here.
If the patient is not a minor, sign here.
Your information will be encrypted.
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