My signature confirms that I have been informed of my rights to privacy regarding my protected health information, under the Health Insurance Portability and Accountability Act of 1996 (HIPPA). I understand that this information can and will be used to:

 

• Provide and coordinate my treatment among a number of health care providers who may be involved in that treatment directly and indirectly.

•  Obtain payment from third party payers or professionals on my behalf for services rendered.

• Conduct normal health care operations and assessments for quality and improvement in patient care services.

 

I have been informed of my health care provider’s Notice of Privacy Practices containing a more complete description of the uses and disclosures of my protected health information. I have been given the right to review and receive a copy of such Notice of Privacy Practices and that I may contact this office 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 in order to carry out my treatment, obtain payment for services or conduct health care services assessments and operations. 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.

 

 

Signature of Patient/Client, Parent or Guardian–––––––––––––––––––––––––––    Date–––––––––––––––––

 

Patient/Client Name:––––––––––––––––––––––––––––––––––––––––––––––––

 

Dependent family members also covered by this acknowledgment:–––––––––––––––––––––––––––––––––

 

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