HIPAA Privacy Notice

This form is intended for the use and/or disclosure of Protected Health Information (PHI) when providing or seeking treatment, payment, and healthcare operations.

This privacy notice contains a thorough and complete description of the uses and/or disclosures of Protected Health Information (PHI) necessary to provide treatment, obtain payment, and perform other healthcare operations. Upon request, the privacy notice will be made available.
To protect your privacy and comply with applicable law, the practice reserves the right to change the practices outlined in its privacy notice.
You are free to request a copy of this notice at any time.
The “Notice of Privacy Practices” contains your rights, as well as the duties and obligations of this office, regarding your protected health information.

Authorization for Communication

The following individuals have my permission to call and speak with the doctor or staff on my behalf:

Name (if other than Patient):
Relationship:

Signature

Signature of Patient:
Date:

Print Name: