Notice of Privacy Practices Acknowledgement
Our Commitment:
- We understand the importance of safeguarding your Protected Health Information (PHI).
- We value your trust and will continue to recognize the importance of holding your PHI as confidential.
- We will hold our employees to strict standards of conduct to ensure the confidentiality of your PHI.
- We maintain physical, electronic and procedural safeguards to comply with state and federal regulations pertaining to PHI.
Our Privacy Notice telling you how this office uses & discloses PHI and what your rights are is posted in the lobby.
(A copy of the Notice of Privacy Practices is available on request)
I understand that, under the Health Insurance Portability & 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 and indirectly.
- Obtain payment from third-party payers.
- Conduct normal healthcare operations such as quality assessments and physician certifications.
I have received, read and understand your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time at the address above to obtain a current copy of the Notice of Privacy Practices.
I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or healthcare operations. I also understand you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions.
I understand that I may revoke this consent in writing at any time, except to the extent that you have taken action relying on this consent.