The Health Insurance Portability & Accountability Act of 1996 (“HIPAA”) is a federal program that requires that all medical records and other individually identifiable health information used or disclosed by us in any form, whether electronically, on paper, or verbally, are kept properly confidential. This Act gives you, the patient, significant new rights to understand and control how your health information is used. “HIPAA” provides penalties for covered entities that
misuse personal health information.

Please read the notice below, check the appropriate box and sign.

I have been informed by you of your Notice of Privacy Practices containing a complete description of the uses and disclosures of my health information. I have been given the opportunity to review such Notice of Privacy Practices prior to signing this acknowledgement and understand that you have the right to change your Notice of Privacy Practices from time to time.

  • This field is for validation purposes and should be left unchanged.