Acknowledgement of Receipt of Notice of Privacy Practices

I understand that under the Health Insurance Portability & Accountability Act of 1996, “HIPPA,” I have certain rights to privacy regarding my protected health information or that of my legal dependent. 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 and indirectly.
• Obtain payment from third-party payers.
• Conduct normal healthcare operations such as quality assessments and physician certifications.

I have received your notice of Privacy Practices which contains a more complete description of the uses and disclosures of protected health information. I understand that this organization may change the content of the Notice of Privacy Practices as needed and that I may request the most recent revision if necessary.

I may request in writing that you restrict how protected health information is used or disclosed to carry out treatment, payment, or health care operations. I also understand that certain restrictions may make it impossible to either bill insurance companies, or provide healthcare in a manner that is within the standard.

(These requests will be considered case by case, and may result in us being unable to honor the request, or deliver treatment in this office.)

have received a copy of this office’s Notice of Privacy Practices.

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.