Notice Of Privacy Practices Acknowledgement​

I understand that, under the Health Insurance Portability and Accountability Act of 1996, (HIPPA), I have certain rights to privacy regarding my protected health information. I understand that the 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 for third-party payers
• Conduct normal healthcare operations, such as quality assessment and physician’s certifications.

I have reviewed/read the office’s Notice of Privacy Practices in the lobby. I understand your Notice of Privacy Practices contains 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 Practice from time to time and that I may contact this organization at any time to obtain a current copy of its 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 operation. I also understand that you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions.