Legacy Spine and Neurological Specialists
Privacy Notice
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

This Privacy Notice is being provided to you as a requirement of a federal law, the Health Insurance Portability and Accountability Act (HIPAA). This Privacy Notice describes how we may use and disclose your protected health information to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information in some cases. Your "protected health information" means any written and oral health information about you, including demographic data that can be used to identify you. This is health information that is created or received by your health care provider, and that relates to your past, present or future physical or mental health or condition.

I. Uses and Disclosures of Protected Health Information
Arkansas Neurosurgery Brain & Spine Clinic, P.A. d/b/a Legacy Spine and Neurological Specialists d/b/a Legacy Neurosurgery Brain & Spine Specialists d/b/a Legacy Neurology d/b/a Pavilion MRI (hereinafter collectively referred to as “Legacy”) may use your protected health information for purposes of providing treatment, obtaining payment for treatment, and conducting health care operations. Your protected health information may be used or disclosed only for these purposes unless Legacy has obtained your authorization or the use or disclosure is otherwise permitted by the HIPAA privacy regulations or state law. Disclosures of your protected health information for the purposes described in this Privacy Notice may be made in writing, orally, or by facsimile. We may choose to communicate with you regarding your protected health information via secure electronic mail, text messages, through our secure Patient Portal or by telephone unless you inform us in writing that you do not wish to be contacted in this manner. We may leave a voice mail on the telephone number you have provided to update you on your treatment, payment, and/or operations.

A. Treatment. We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party for treatment purposes. For example, we may disclose your protected health information to a pharmacy to fill a prescription or to a laboratory to order a blood test. We may also disclose protected health information to physicians who may be treating you or consulting with the clinic with respect to your care. In some cases, we may also disclose your protected health information to an outside treatment provider for purposes of the treatment activities of the other provider.

B. Payment. Your protected health information will be used, as needed, to obtain payment for the services that we provide. This may include certain communications to your health insurance company to get approval for the procedure that we have scheduled. For example, we may need to disclose information to your health insurance company to get prior approval for the surgery. We may also disclose protected health information to your health insurance company to determine whether you are eligible for benefits or whether a particular service is covered under your health plan. In order to get payment for the services we provide to you, we may also need to disclose your protected health information to your health insurance company to demonstrate the medical necessity of the services or, as required by your insurance company, for utilization review. We may also disclose patient information to another provider involved in your care for the other providers payment activities. This may include disclosure of demographic information to anesthesia care providers for payment of their services.

C. Operations. We may use or disclose your protected health information, as necessary, for our own health care operations to facilitate the function of the ASC and to provide quality care to all patients. Health care operations include such activities as: quality assessment and improvement activities, employee review activities, training programs including those in which students, trainees, or practitioners in health care learn under supervision, accreditation, certification, licensing or credentialing activities, review and auditing, including compliance reviews, medical reviews, legal services and maintaining compliance programs, and business management and general administrative activities.
In certain situations, we may also disclose patient information to another provider or health plan for their health care operations.

D. Other Uses and Disclosures. As part of treatment, payment and health care operations, we may also use or disclose your protected health information for the following purposes: to remind you of your surgery date, to inform you of potential treatment alternatives or options, to inform you of health-related benefits or services that may be of interest to you, or to contact you to raise funds for the clinic or an institutional foundation related to the clinic. If you do not wish to be contacted regarding fundraising, please contact our Privacy Officer.

II. Uses and Disclosures Beyond Treatment, Payment, and Health Care Operations Permitted Without Authorization or Opportunity to Object
Federal privacy rules allow us to use or disclose your protected health information without your permission or authorization for a number of reasons including the following:

A. When Legally Required. We will disclose your protected health information when we are required to do so by any federal, state or local law

B. When There Are Risks to Public Health. We may disclose your protected health information for the following public activities and purposes:
· To prevent, control, or report disease, injury or disability as permitted by law.
· To report vital events such as birth or death as permitted or required by law.
· To conduct public health surveillance, investigations and interventions as permitted or required by law.
· To collect or report adverse events and product defects, track FDA regulated products, enable product recalls, repairs or replacements to the FDA and to conduct post marketing surveillance.
· To notify a person who has been exposed to a communicable disease or who may be at risk of contracting or spreading a disease as authorized by law.
· To report to an employer information about an individual who is a member of the workforce as legally permitted or required.

C. To Report Suspended Abuse, Neglect Or Domestic Violence. We may notify government authorities if we believe that a patient is the victim of abuse, neglect or domestic violence. We will make this disclosure only when specifically required or authorized by law or when the patient agrees to the disclosure.

D. To Conduct Health Oversight Activities. We may disclose your protected health information to a health oversight agency for activities including audits; civil, administrative, or criminal investigations, proceedings, or actions; inspections; licensure or disciplinary actions; or other activities necessary for appropriate oversight as authorized by law. We will not disclose your health information under this authority if you are the subject of an investigation and your health information is not directly related to your receipt of health care or public benefits.

E. In Connection With Judicial And Administrative Proceedings. We may disclose your protected health information in the course of any judicial or administrative proceeding in response to an order of a court or administrative tribunal as expressly authorized by such order. In certain circumstances, we may disclose your protected health information in response to a subpoena to the extent authorized by state law if we receive satisfactory assurances that you have been notified of the request or that an effort was made to secure a protective order.

F. For Law Enforcement Purposes. We may disclose your protected health information to a law enforcement official for law enforcement purposes as follows:
· As required by law for reporting of certain types of wounds or other physical injuries.
· Pursuant to court order, court-ordered warrant, subpoena, summons or similar process.
· For the purpose of identifying or locating a suspect, fugitive, material witness or missing person.
· Under certain limited circumstances, when you are the victim of a crime.
· To a law enforcement official if the clinic has a suspicion that your health condition was the result of criminal conduct.
· In an emergency to report a crime.

G. To Coroners, Funeral Directors, and for Organ Donation. We may disclose protected health information to a coroner or medical examiner for identification purposes, to determine cause of death or for the coroner or medical examiner to perform other duties authorized by law. We may also disclose protected health information to a funeral director, as authorized by law, in order to permit the funeral director to carry out their duties. We may disclose such information in reasonable anticipation of death. Protected health information may be used and disclosed for cadaveric organ, eye or tissue donation purposes.

H. For Research Purposes. We may use or disclose your protected health information for research when the use or disclosure for research has been approved by an institutional review board that has reviewed the research proposal and research protocols to address the privacy of your protected health information.

I. In the Event of a Serious Threat to Health or Safety. We may, consistent with applicable law and ethical standards of conduct, use or disclose your protected health information if we believe, in good faith, that such use or disclosure is necessary to prevent or lessen a serious and imminent threat to your health or safety or to the health and safety of the public.

J. For Specified Government Functions. In certain circumstances, federal regulations authorize us to use or disclose your protected health information to facilitate specified government functions relating to military and veterans activities, national security and intelligence activities, protective services for the President and others, medical suitability determinations, correctional institutions, and law enforcement custodial situations.
K. For Worker's Compensation. We may release your health information to comply with worker's compensation laws or similar programs.

III. Uses and Disclosures Permitted without Authorization but with Opportunity to Object
We may disclose your protected health information to your family member or a close personal friend if it is directly relevant to the persons involvement in your surgery or payment related to your surgery. We can also disclose your information in connection with trying to locate or notify family members or others involved in your care concerning your location, condition or death.
You may object to these disclosures. If you do not object to these disclosures or we can infer from the circumstances that you do not object or we determine, in the exercise of our professional judgment, that it is in your best interests for us to make disclosure of information that is directly relevant to the persons involvement with your care, we may disclose your protected health information as described.

IV. Uses and Disclosures Which You Authorize
Other than as stated above, we will not disclose your health information other than with your written authorization. You may revoke your authorization in writing at any time except to the extent that we have taken action in reliance upon the authorization.

V. Your Rights
You have the following rights regarding your health information:

A. The right to inspect and copy your protected health information. You may inspect and obtain a copy of your protected health information that is contained in a designated record set for as long as we maintain the protected health information. A "designated record set" contains medical and billing records and any other records that your surgeon and the clinic uses for making decisions about you. Under federal law, however, you may not inspect or copy the following records: psychotherapy notes; information compiled in reasonable anticipation of, or for use in, a civil, criminal, or administrative action or proceeding; and protected health information that is subject to a law that prohibits access to protected health information. Depending on the circumstances, you may have the right to have a decision to deny access reviewed.
We may deny your request to inspect or copy your protected health information if, in our professional judgment, we determine that the access requested is likely to endanger your life or safety or that of another person, or that it is likely to cause substantial harm to another person referenced within the information. You have the right to request a review of this decision.
To inspect and copy your medical information, you must submit a written request to the Privacy Officer whose contact information is listed on the last page of this Privacy Notice. If you request a copy of your information, we may charge you a fee for the costs of copying, mailing or other costs incurred by us in complying with your request.
Please contact our Privacy Officer if you have questions about access to your medical record.

B. The right to request a restriction on uses and disclosures of your protected health information. You may ask us not to use or disclose certain parts of your protected health information for the purposes of treatment, payment or health care operations. You may also request that we not disclose your health information to family members or friends who may be involved in your care or for notification purposes as described in this Privacy Notice. Your request must state the specific restriction requested and to whom you want the restriction to apply.
The clinic is not required to agree to a restriction that you may request. We will notify you if we deny your request to a restriction. If the clinic does agree to the requested restriction, we may not use or disclose your protected health information in violation of that restriction unless it is needed to provide emergency treatment. Under certain circumstances, we may terminate our agreement to a restriction. You may request a restriction by contacting the Privacy Officer.

C. The right to request to receive confidential communications from us by alternative means or at an alternative location. You have the right to request that we communicate with you in certain ways. We will accommodate reasonable requests. We may condition this accommodation by asking you for information as to how payment will be handled or specification of an alternative address or other method of contact. We will not require you to provide an explanation for your request. Requests must be made in writing to our Privacy Officer.

D. The right to request amendments to your protected health information. You may request an amendment of protected health information about you in a designated record set for as long as we maintain this information. In certain cases, we may deny your request for an amendment. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. Requests for amendment must be in writing and must be directed to our Privacy Officer. In this written request, you must also provide a reason to support the requested amendments.

E. The right to receive an accounting. You have the right to request an accounting of certain disclosures of your protected health information made by the clinic. This right applies to disclosures for purposes other than treatment, payment or health care operations as described in this Privacy Notice. We are also not required to account for disclosures that you requested, disclosures that you agreed to by signing an authorization form, disclosures for a clinic directory, to friends or family members involved in your care, or certain other disclosures we are permitted to make without your authorization. The request for an accounting must be made in writing to our Privacy Officer. The request should specify the time period sought for the accounting. We are not required to provide an accounting for disclosures that take place prior to April 14, 2003. Accounting requests may not be made for periods of time in excess of six years. We will provide the first accounting you request during any 12-month period without charge. Subsequent accounting requests may be subject to a reasonable cost-based fee.

F. The right to obtain a paper copy of this notice. Upon request, we will provide a separate paper copy of this notice even if you have already received a copy of the notice or have agreed to accept this notice electronically.

VI. Our Duties
The clinic is required by law to maintain the privacy of your health information and to provide you with this Privacy Notice of our duties and privacy practices. We are required to abide by terms of this Notice as may be amended from time to time. We reserve the right to change the terms of this Notice and to make the new Notice provisions effective for all future protected health information that we maintain. If the clinic changes its Notice, we will provide a copy of the revised Notice by sending a copy of the revised Notice via regular mail or through in-person contact.

VII. Complaints
You have the right to express complaints to the clinic and to the Secretary of Health and Human Services if you believe that your privacy rights have been violated. You may complain to the clinic by contacting the clinics Privacy Officer verbally or in writing, using the contact information below. We encourage you to express any concerns you may have regarding the privacy of your information. You will not be retaliated against in any way for filing a complaint.

VIII. Contact Person
The clinics contact person for all issues regarding patient privacy and your rights under the federal privacy standards is the Privacy Officer, Allie Mills. Information regarding matters covered by this Notice can be requested by contacting the Privacy Officer. If you feel that your privacy rights have been violated by this clinic you may submit a complaint to our Privacy Officer by sending it to:
Legacy Spine and Neurological Specialists
8201 Cantrell Rd STE 265
Little Rock, AR 72227
ATTN: Privacy Officer
The Privacy Officer can be contacted by telephone at 501-661-0077 .
IX. Effective Date
This Notice is effective January 13, 2008.

LEGACY SPINE AND NEUROLOGICAL SPECIALISTS
INSURANCE ASSIGNMENT AND PAYMENT POLICY STATEMENT AND AGREEMENT
I agree to be personally responsible for the payment of all charges for services rendered to me (or if I am the guarantor of payment, the services rendered, on behalf of the individual for whom I have assumed financial responsibility). I understand that while others may also be responsible for paying these charges by virtue of an express or implied agreement, or otherwise, I am responsible for paying for all charges. I agree to pay all co-insurance, co-pays and deductibles no later than at the time services are rendered. I understand that payment can be paid by cash, check, or credit card (VISA, MasterCard, American Express or Discover and when needed by Care Credit).
Our office is happy to file medical claims with your insurance carrier. Once we have received payment from your insurance company, any remaining balance on your account not already collected is due and payable within thirty (30) days of receiving the insurance payment. If full payment is not received, Uses and Disclosures of Protected Health Information
Arkansas Neurosurgery Brain & Spine Clinic, P.A. d/b/a Legacy Spine and Neurological Specialists d/b/a Legacy Neurosurgery Brain & Spine Specialists d/b/a Legacy Neurology d/b/a Pavilion MRI (hereinafter collectively referred to as “Legacy”) may charge interest beginning on the thirty-first (31st) day after insurance payments have been received at the annual rate of ten percent (10%) on any unpaid balance until paid in full. Legacy Neurosurgery also reserves the right to utilize the services of a collection agency in collecting delinquent accounts. If a collection service is utilized, I agree to pay all such costs incurred in collecting my account balance, including attorneys fees. If my check is returned for insufficient funds, I agree to pay a returned check fee of $25 for each occurrence.

I hereby assign to Legacy any and all rights, benefits, and payments to which I may be entitled to receive from any healthcare or liability insurance policy, Medicare or Medicaid. I will hold Legacy harmless from any reduction in healthcare benefits from my insurance company resulting from noncompliance with any clause or condition contained in my policy which may require: Notification, Pre-certification, Prior to Retrospective Authorization, or Utilization Review of any of the medical services that I receive. This assignment of insurance benefits will remain in effect until revoked by me in writing and communicated to this office. I am financially responsible for all amounts not covered by insurance.

I hereby authorize this office, at their discretion, to disclose all or part of my medical records or any other information contained in my file, to any person, corporation, or other entity which is or may be liable for all or part of the charges, including insurance companies, workers compensation carriers, welfare funds, the Social Security Administration or its intermediaries or carriers, as well as any agency engaged by this office to facilitate collection of any unpaid charges. This office may also disclose medical information to third parties to assist in the collection of any unpaid balance due on this account or to any insurance company representing this office or its physicians.
ANY CHECK BEARING THE WORDS "PAID-IN-FULL" (AND/OR OTHER WORDS OF SIMILAR MEANING) WILL BE TREATED AS A PARTIAL PAYMENT ON THE BALANCE OF YOUR PATIENT ACCOUNT. NO ACCEPTANCE OF A PARTIAL PAYMENT SHALL CONSTITUTE AN ACCORD AND SATISFACTION, REGARDLESS OF ANY TERMS OR RESTRICTIONS INDICATED ON, OR INCLUDED WITH, ANY PAYMENT TO LEGACY. UNLESS OTHERWISE EXPRESSLY AGREED TO IN WRITING BY THE PRESIDENT OR CHIEF EXECUTIVE OFFICER OF LEGACY ON A FORM PROVIDED BY THE LEGACY , NO ACCEPTANCE OF A PARTIAL PAYMENT SHALL WAIVE OR RELEASE ANY RIGHT OF THE CLINIC TO RECEIVE PAYMENT IN FULL OF YOUR PATIENT ACCOUNT. ANY COMMUNICATIONS CONCERNING DISPUTED DEBTS, ACCOUNTS OR PROPOSED SETTLEMENTS, AND ANY PAYMENT OFFERED IN SATISFACTION OR SETTLEMENT OF AN ACCOUNT OR OTHER DEBT MUST BE SENT VIA CERTIFIED MAIL, RETURN RECEIPT REQUESTED, WITH RESTRICTED DELIVERY TO Allie Mills, Director of Operations, at 5800 W. 10th Street, Ste 206, Little Rock, AR 72204.
PAYMENT POLICY

As a courtesy to our patients, we make every attempt to contact your insurance carrier and verify your benefits prior to your arrival. You are expected to pay any deductibles, coinsurance and/or co-pay amounts that are due at the time of service. If we are unable to verify your benefits in advance, you will be required to pay for your visit in full at the time of service. At such time as your insurance carrier remits payment for services rendered, your payment (less deductible and co-pay) will be refunded.
If you do not have any health insurance, you will be required to pay for your initial and subsequent care prior to all services. The scheduling staff will notify you of the minimum down-payment amounts.

All patient owed fees are due prior to the services being rendered. If you cannot make payment in full we do have a financial service called Care Credit that can possibly assist you. Ask our financial counselor for assistance if needed.

If you are being seen as the result of a motor vehicle accident, personal injury, or third-party liability, please notify our scheduling staff prior to your appointment and complete the attached form entirely with your attorneys information if you already have one.
As of May 1st, 2018 a $50 dollar no show fee will be applied to your account if you fail to cancel your appointment within 24 hours of your scheduled appointment time. This will be applied to EACH appointment missed. Therefore, if you have multiple appointments in one day this fee could increase. This fee will have to be paid in full before you are able to reschedule your appointment. While we understand things may arise that are out of your control no showing to an appointment or canceling your appointment without sufficient notice creates challenges in scheduling and compromises our ability to provide timely care to our patients needing appointments.
We accept the following payment methods:
CASH, Personal Check, Credit Card, Debit Card, and Care Credit.

If there is an overpayment or excess payment on the patient's account, we will review the patient's account with Freeway Surgery Center LLC to determine whether any amount is due. By signing below, you agree that if there is an amount due the excess payment will be transferred to Freeway Surgery Center LLC and applied to the outstanding balance. If there is no amount due on the patient’s Freeway Surgery Center LLC account then a refund will be processed.
Financial Disclosure:
The Patient Protection and Affordable Care Act of 2010, as amended by the Health Care and Education Reconciliation Act of 2010, requires physicians who refer patients for MRI, CT and/or PET scans/services and also provide the scans/services to inform Medicare patients in writing, at the time of the referral, that the patient may obtain the advanced imaging services (MRI, CT and/or PET) from other suppliers.
Should your Legacy physician determine that you should need a Magnetic Resonance Imaging (MRI) scan and you are a Medicare patient, Federal law requires your physician to inform you in writing at the time of the MRI referral that you may obtain the MRI from Legacy Neurosurgery Spine and Brain Specialists, one of the alternative suppliers listed below, or any other supplier of your choice. Below is a list of alternative suppliers within a 25-mile radius of our office. The following list is meant to provide you with freedom of choice and does not constitute an endorsement or recommendation of any one supplier or provider.
1. Arkansas Specialty MRI Center
600 S McKinley St. Little Rock, AR 72205, 501-978-2192
2. RAPA
500 S University Ave, Little Rock, AR 72205, 501-664-3914
3. Chenal MRI
11300 Financial Centre Parkway, Little Rock, AR 72211, 501-211-2502

4. Premier MRI
906 S Broadway, Little Rock, AR 72201, 501-374-7674

5. Baptist Health Imaging Center
2400 N Rodney Parham Little Rock, AR 72212, 501-202-6750

By signing this document I confirm that at the time of scheduling for my MRI/MRA I was notified of the above rights as a patient.

THIRD PARTY LIABILITY AGREEMENT
I, the undersigned party, acknowledge that I, or someone for whom I am legally or financially responsible (as applicable, "Patient "), am or will be a patient of Freeway Surgery Center, LLC and/or Arkansas Brain and Spine Clinic, P.A. d/b/a Arkansas Neurosurgery Clinic d/b/a Legacy Neurosurgery d/b/a Legacy Neurology d/b/a Pavilion MRI (individually and collectively, the "Provider "). Provider has or will furnish to Patient certain medical services and treatment for injuries sustained by Patient which have been caused by the fault or neglect of another person (the "Treatment "). Patient acknowledges that Arkansas law grants Provider a lien on any claim, right of action, and money to which Patient is entitled for the value the Treatment provided to Patient, and to costs and attorneys' fees incurred in enforcing the lien. Patient authorizes Provider to file medical liens, at Provider's discretion, to recover the cost of the Treatment from any damages or insurance benefits paid by a responsible third party or insurer, which damages or benefits are attributable to Patient's medical expenses for the Treatment. Patient acknowledges and agrees that the filing of such a lien shall be deemed a collection action against the responsible third party or against such responsible third party's insurer, and not against Patient. In addition to the medical lien authorized herein, Patient grants Provider a security interest in any damages or insurance benefits paid by a responsible third party or such party's insurer which are attributable to Patient's medical expenses. Patient authorizes Provider, at Provider's discretion, to file financing statements under the Uniform Commercial Code evidencing such liens.
Patient agrees to furnish Provider, upon request, complete and accurate information regarding the parties involved in the accident causing Patient's injuries and their insurers, all circumstances of the accident, and copies of all reports or insurance claims filed or prepared in connection with the accident. Patient agrees to promptly update Provider on the status of any settlement negotiations (both in-court and out-of-court) between Patient, the responsible third party and any insurance companies. In the event Patient files a lawsuit against the responsible third party or such party's insurer, Patient agrees to furnish Provider with a file-marked copy of the complaint filed in such lawsuit within three (3) days after filing. Provider shall be entitled to assert a medical lien in such lawsuit. Patient agrees that Provider shall be allowed to participate in any settlement (whether in-court or out-of-court) as needed to enforce Provider's lien and collect the cost of Treatment from any damages or insurance benefits for Patient's medical expenses.

Patient acknowledges that Provider may be required to bring any action to collect the cost of the Treatment within two (2) years from the later of the date the services were performed or the last partial payment to Patient's account. Patient acknowledges that Patient may be able to pursue legal action against the responsible third party after the expiration of such two (2) year period. If sent to our collection agency you will be responsible for a collection fee up to 35% of the amount sent to the collection agency which will be added to the principal balance owed. In consideration of the foregoing and as a material inducement to Provider's agreement to treat Patient, Patient voluntarily agrees to grant an extension of the two (2) year enforcement period for an additional two (2) years to allow Provider to enforce Provider's lien rights for not less than four (4) years following the date that medical Treatment was last provided to Patient. In addition, Patient agrees to promptly make nominal payments on Patient's account balance to ensure the extension of the original enforcement period pending the filing of any action against a responsible third party. Nothing contained in this paragraph shall relieve Patient of the duty to pay the balance of Patient's account in full.
Patient authorizes Provider, at Provider's discretion, to disclose Patient's medical records or any other information contained in Patient's file, to any person, entity or insurance company as needed to assert the lien rights granted in this agreement or otherwise available to Provider. Nothing contained in this agreement shall limit or prejudice the rights of Provider under any other agreement between Patient and Provider, or Provider's right to enforce any statutory liens.
I acknowledge that I have read, understand and agree to be legally bound by the obligations contained in this agreement. If signing on behalf of another person, I represent and warrant that I am legally authorized to act on behalf of such person and to legally bind such person to the obligations contained in this agreement.

ACKNOWLEDGMENT OF RECEIPT AND UNDERSTANDING OF PRIVACY NOTICE AND FINANCIAL DISCLOSURES; AGREEMENT TO INSURANCE ASSIGNMENT AND PAYMENT POLICY STATEMENT AND AGREEMENT AND THIRD PARTY LIABILITY AGREEMENT
By signing this document I am acknowledging that I am a patient of Arkansas Neurosurgery Brain & Spine Clinic, P.A. d/b/a Legacy Spine and Neurological Specialists d/b/a Legacy Neurosurgery Brain & Spine Specialists d/b/a Legacy Neurology d/b/a Pavilion MRI (hereinafter collectively referred to as “Legacy”) and that I have read, agree, and understand to be legally bound by the Terms of the Third Party Liability Agreement, Insurance Assignment and Payment Policy Statement and Agreement. I also read and understand the Patient Privacy Notice and have no objections to the policies as described therein including, but not limited to, policies regarding forms of communication between me and Legacy of Protected Health Information. I understand these and have been given an opportunity as well as contact information should I desire any additional information.