Notice of Privacy Practices


I understand that, under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health insurance. I understand that this information will be used to:

·         Conduct, plan and direct my treatment and follow-ups 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; equality assessments and physician certifications.

I have received, ready 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 the time to time and that I may contact this organization at any time at the address below to obtain 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 that you are not required to agree to my requested restrictions but if you do agree that you are bound to abide by such restrictions.