Acknowledgment of Receipt
Notice of Privacy Practices
This office maintains medical records that describe your health history, symptoms, examination findings, test results, diagnoses, treatment, and plans for future care or treatment. This information may be used to provide medical care, coordinate treatment, obtain payment for services, and support normal healthcare operations.
Our practice is required by law to maintain the privacy of your protected health information and to provide you with a Notice of Privacy Practices that describes how your medical information may be used and disclosed, as well as your rights regarding that information.
A copy of our Notice of Privacy Practices is available to you and is also posted in our office and on our website.
Federal law provides additional protections for records related to substance use disorder treatment that are maintained by federally assisted programs. These records may only be used or disclosed as permitted under federal law (42 CFR Part 2) or with patient authorization. Information related to substance use disorder treatment may not be used or disclosed in certain legal or administrative proceedings and may not be used to discriminate against patients in employment, housing, or access to healthcare.
Patient Acknowledgment
I acknowledge that I have been offered a copy of this practice’s Notice of Privacy Practices, which explains how my medical information may be used and disclosed and describes my rights regarding my protected health information.
I understand that the practice reserves the right to change the terms of its Notice of Privacy Practices and that the current notice will be available upon request.
If I have questions or concerns regarding privacy practices, I may contact the practice for additional information.