HIPAA- Privacy Statement

  • Please select your correct location for each form.
  • I understand that under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information (PHI). 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 the treatment directly and indirectly.
    • Obtain payment from third-party payers
    • Conduct normal healthcare operations such as quality assessments and physician certifications
    I received, read, and understand your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my PHI. I understand that this organization has the right to change its Notice of Practices from time to time and that I may contact this organization at any time to obtain a current copy of Notice of Privacy Practices.