ACKNOWLEDGEMENT Of RECEIPT OF NOTICE OF PRIVACY PRACTICES “You May Refuse to Sign This Acknowledgement” I have received a copy of this offices Notice of Privacy Practices. PATIENT CONSENT I understand that, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA). I have certain right to privacy regarding my protected health information. I understand that this information can and will be used to: Conduct, Plan and direct my treatment and follow-up among the healthcare providers Obtain payment form third-party payers. Conduct normal healthcare operations such as quality assessments and physician certification. I have been informed by you and your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I have been given the right to review such Notice of Privacy prior to signing this consent. I understand that I may contact this organization at any time to obtain a copy of Privacy Practices. I Understand I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment, or health care operations. I also understand that you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions. I understand that I may revoke this consent in writing at any time, except to the extent that you have taken action relying on this consent. The following individual or company has the right to receive my information: Name: Address Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Company (if applicable): Contact NumberRelationship to Patient: The following individual or company does NOT have the right to receive my information:Name Company SignatureDate MM slash DD slash YYYY CAPTCHANameThis field is for validation purposes and should be left unchanged.