ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES. This is to confirm that I have received a copy of this office’s Notice of Privacy Practices. I understand that I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to conduct, plan and direct my treatment, obtain payment from third party payors and conduct normal healthcare operations such as quality assessments and accreditation.
ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES. I have received a copy of Allendale Dental’s NOTICE OF PRIVACY PRACTICES, and fully understand the “Payment Policy”, outlined above, accepting responsibility for all charges, deductibles, co-pays and uncovered items, not paid by my insurance.
ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES. I acknowledge that I was provided a copy of the HIPAA Notice of Privacy Practices and that I have read (or had the opportunity to read if I so chose) and understand the Notice.
ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES. Regarding the Use & Disclosure of Protected Health Information
ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES. By signing this form, I agree to the terms and acknowledge that I have been provided with a copy of the Informed Consent and Notice of Privacy Practices document. This document provides information about agreements with my therapist regarding participation in therapy and how my protected health information may be used and disclosed. I have read it in full and understand these documents are subject to change. If I have any questions about my Notice of Privacy Practices, or wish to receive a copy of any revisions of the Informed Consent and Notice of Privacy Practices, I acknowledge that I may submit my request to Glendale-Arcadia-Counseling at 000 X. Xxxxx Xxxx., Xxx. 000 Xxxxxxxx, XX 00000, (000)000-0000 Xxxxx Xxxxxxx, LCSW (LCS14276) is licensed to diagnose and treat mental health problems. Xxxxx Xxxxxxx, M. A. AMFT (12071) provides mental health treatment under the supervision of Xxxxx Xxxxxxx, LCSW (LCS14276).
ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES. Comprehensive Cancer Centers of Nevada is committed to protecting your privacy and ensuring that your health information is used and disclosed appropriately. This Notice of Privacy Practices identifies all potential uses and disclosures of your health information by our practice and outlines your rights with regard to your health information. Please sign the form below to acknowledge that you have received our Notice of Privacy Practices. I acknowledge that I have received a copy of the Notice of Privacy Practices of Comprehensive Cancer Centers of Nevada. Date: Name: Name of Personal Representative (if appropriate): Date acknowledgment received: ) - OR- Reason acknowledgment was not obtained: Name: Date of Birth: Race/Ethnicity: Preferred Language: Preferred Method of Contact Email: Cell: Home: Other: Married Single Widowed Divorced Life Partner My Care Plus, the Patient Portal (the “Portal”) offers convenient and secure access to your personal health record. As the patient, you are in control of your Portal record: we will not activate your personal account unless you authorize us to do so. Because personal identifying information is available via the Portal, it is very important that you keep your password private. Do not share your password with anyone or write it in a place easily accessible to others. If you choose not to execute this User Electronic Mail Authorization Form, you will not be able to access the Portal. If you choose to submit this form, you understand you are consenting for us to email you a unique link that you will use to create a password in order to access the Portal. Please look for an email from My Care Plus promptly after submitting this form. For your protection, the link is designed to expire quickly if not used. If you should change email addresses, please contact your physician’s office in order to provide your new email contact information so that you will continue to receive updates and other pertinent information. Please choose an email address that will not be subject to access by anyone you do not trust. If you wish to discontinue utilizing the Portal, please contact your physician’s office.
ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES. I acknowledge that I have received a copy of the Xxxxx Xxxxxxx Notice of Privacy Practices. Patient Name: Birth Date: _ (first) (m. initial) (last) Address: Phone #: (city) (state) (zip code) (if known) Signature of Patient Only: Date:
ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES. I acknowledge that I was provided a copy of the HIPAA Notice of Privacy Practices and that I have read (or had the opportunity to read if I so chose) and understand the Notice. The ACADEMY FOOT & ANKLE SPECIALISTS HIPAA rights are also posted in lobby and at xxx.xxxxxxxxxxxxxxx.xxx.
ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES. I acknowledge that I was provided a copy of the HIPAA Notice of Privacy Practices and that I have read (or had the opportunity to read if I so chose) and understand the Notice. The SAPC HIPAA rights are also posted in lobby and at xxx.xxxxxxxxxxx.xxx.
ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES. We are legally required to provide you with a copy of our NOTICE OF PRIVACY PRACTICES the first time you receive care at UC Health. If you are here for emergency medical treatment, you will be given a copy as soon as possible.
