grapevinewomenshealth.com - Notice of Privacy Practices

Notice of Privacy Practices
By signing below, I acknowledge that I have received a copy of Grapevine Women’s Health and Gynecology, LLC Notice of Privacy Practices.

I understand that Grapevine Women’s Health & Gynecology may use or disclose my health information to carry out treatment, payment, or healthcare operations. Health information pertains to any and all information relating to healthcare services provided to me by Grapevine Women’s Health & Gynecology including information provided to me prior to the date I signed this form.

I understand that if I have questions or concerns about my rights or the privacy of Grapevine Women’s Health & Gynecology, I may contact the HIPAA Privacy Officer at the practice address:

Grapevine Women’s Health & Gynecology, LLC

5880 NE Cornell Rd, Suite C

Hillsboro, OR 97124
Signature:

Clear
Name of Patient (Print):
Date:

Month Day Year
Date
Signature of Patient Representative: (Required if the patient is a minor or an adult who is unable to sign this form)

Clear
Relationship of Patient Representative to Patient:
Documentation of Attempt to Obtain Acknowledgment of Receipt of Notice of Privacy Practices

Attempt to Obtain Acknowledgment

An attempt was made to obtain an acknowledgment of receipt of the “Notice of Privacy Practices” on Type a label
The acknowledgment was not obtained because:

The patient was undergoing emergency treatment The patient declined to sign the acknowledgment Other
Name of Staff Member:
Name of Patient (Print):
Date:

Month Day Year
Date
Should be Empty: