By signing below, I acknowledge that I have received a copy of Grapevine Women’s Health and Gynecology, LLC Notice of Privacy Practices.
I understand that Grapevine Women’s Health & Gynecology may use or disclose my health information to carry out treatment, payment, or healthcare operations. Health information pertains to any and all information relating to healthcare services provided to me by Grapevine Women’s Health & Gynecology including information provided to me prior to the date I signed this form.
I understand that if I have questions or concerns about my rights or the privacy of Grapevine Women’s Health & Gynecology, I may contact the HIPAA Privacy Officer at the practice address:
Grapevine Women’s Health & Gynecology, LLC
5880 NE Cornell Rd, Suite C
Hillsboro, OR 97124