NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT
I understand that, under the Health Insurance Portability & Accountability Act (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 acknowledge that I have read your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I understand that you have the right to change your Notice of Privacy Practices from time to time and that I may contact you 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 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.