The Health Insurance Portability and Accountability act of 1996 (HIPAA) requires this office comply with certain rules regarding the maintenance of the privacy of your information that we have collected and will collect in the future.
To comply with one of HIPAA’s requirements we are giving you a copy of our Notice of Privacy Practices as seen on this webpage and available for download and printing. This Notice of Privacy Practices contains the information that HIPAA requires us to disclose regarding our privacy practices.
From time to time it may be necessary for us to make disclosures of your information in connection with our treatment. For example, we may make a referral to or consult with another health care professional or otherwise make disclosures of your information in connection with providing or coordinating your information.
Please sign this form below to acknowledge that you have today either received or reviewed a copy of our notice of privacy practices.
I acknowledge that I have today received a copy of the Notice of Privacy Practices.
DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.