REQUIREMENTS OF HIPAA

NOTICE OF PRIVACY PRACTICES
PROGRAM PARTICIPANT'S NAME
REQUIREMENTS OF HIPAA

You can view the entire PDF by choosing "Preview PDF" below
Please review our Privacy Notice. Sign below if you so choose. You do not have to sign this form if you do not want to. If you decide you do not want to sign it, we will provide you the services for which you are eligible anyways. We will still apply our Privacy Practices to your protected health information. If you do sign this form, please return it as requested. Thank you for your cooperation
PARTICIPANT OR GUARDIAN'S SIGNATURE

Clear
DATE

MonthDayYear
Date
NOTE: NEW GATEWAYS, INC. HAS THE RIGHT TO CHANGE THE TERMS OF THIS NOTICE AT ANY TIME. YOU WILL BE INFORMED IMMEDIATELY IF ANY CHANGES OCCUR.
Should be Empty: