Notice of Privacy Practice Client Acknowledgement
I have received and understand this practice's Notice of Privacy Practices written in plain language.
The notice provides in detail the uses & disclosures of my protected health information that may be made by this practice, my individual rights and the practice's legal duties with respect to my health information. This includes, but is not limited to:
- A statement that this practice is required by law to maintain the privacy of protected health
- A statement that this practice is required to abide by the terms of the notice currently in effect.
- Types of uses & disclosures that this practice is permitted to make for each of the following purposes: treatment, payment & health care operations.
- A description of each of the others purposes for which this practice is permitted or required to use or disclose protected health information without my written consent or authorization.
- A description of uses & disclosures that are prohibited or materially limited by law.
- A description of any other purpose, uses & disclosures that will be made only with my written authorization & that I may revoke such authorization.
My individual rights with respect to protected health information & a brief description of how I may exercise these rights in relation to:
- The right to complain to this practice & to the secretary of the HHS if I believe my privacy rights have been violated, & that no retaliatory actions will be used against me in the event of such a complaint.
- The right to request restrictions on certain uses & disclosures of my protected health information, and that this practice is required to agree to requested restrictions.
- The right to received confidential communications of protected health information.
- The right to inspect & copy protected health information.
- The right to amend protected health information.
- The right to receive an accounting of disclosures of protected health information.
- The right to obtain a paper copy of the Notice of Privacy Practices from this practice upon
This practice reserves the right to change the terms of its Notice of Privacy Practices & make new provisions effective for all protected health information that it maintains. If changes occur, this practice will provide me with a revised Notice of Privacy Practices upon request.