Notice of Privacy Practices Acknowledgement
I understand that, under the Health Insurance Portability & Accountability Act of 1996 ("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 have received, read 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 time to time and that I may contact this organization at any time at the address below to obtain a current copy of the Notice of Private 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 health care operations. I also understand you are not required to agree to my requested restrictions, but if you agree then you are bound to abide by such restrictions.
-
Patient Name: ______________________________________________
Relationship to Patient: _______________________________________
Signature: _________________________________________________
Date: _____________________________________________________
I attempted to obtain the patient's signature in acknowledgement of this Notice of Privacy Practices Acknowledgement, but was able to do so as documented below.
Date: __________ Initials: _______ Reason: _____________________________________
Orthopaedic Medical Group and Athletic Rehabilitation Center, Inc.
1050 Lakes Drive
Suite 100
West Covina, CA 91790
Tel: 626.918.6655
Fax: 626.918.6633
VIEW MAP >>