I understand that under the Health Insurance Portability Accountability Act of 1996 (HIPAA), I have certain rights regarding my protected health information.
I have received, read, and understood the Notice of Privacy Practices, containing a description of the uses and disclosures of my health information.
I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact thsi office at any time to obtain a current copy of the Notice of Privacy Practices.
I understand that the office will be unable to speak to anyone regarding my health information unless they are expressly named below, with no exceptions, unless otherwise dictated by HIPAA laws.
I understand that I may have to update this form from time to time, and I may request to remove or add anyone I see fit, at any time.