Notice of Privacy Practices Acknowledgement

Under the Health Insurance Portability & Accountability Act of 1996 (“HIPAA”), you have certain rights to privacy regarding my protected health information. This information can 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.

Please be advised that this organization has the right to change its Notice of Privacy Practices from time to time. You may contact this organization at any time at the address above to obtain a current copy of the Notice of Privacy Practices.

You may request in writing that we restrict how your private information is used or disclosed to carry out treatment, payment or health care operations. While we are not required to agree to your requested restrictions, if we do agree then we are bound to abide by such restrictions.