grapevinewomenshealth.com - HIPAA Acknowledgement

HIPAA Acknowledgement
By signing below, I acknowledge that I have received a copy of Grapevine Women’s Health & 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 Road, Suite C

Hillsboro, OR 97124

971-228-8097
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Name of Patient (PRINT)
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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:

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