Acknowledgment of Receipt of Notice of Privacy Practices

Acknowledgment of Receipt of Notice of Privacy Practices

I understand that, under the Health Insurance Portability & Accountability Act of 1996 ("HIPAA"), 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 and follow-up among the multiple health care providers who may be involved in that treatment directly and indirectly.
- Obtain payment from third-party payers.
- Conduct normal health care operations such as quality assessments and physician certifications.
I have received, read and understand the Notice of Privacy Practices document containing a more complete description of the uses and disclosures of my health information. I understand that the Famalao'an Wellness Center ("Practice") has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time at the address below for a current copy of the Notice of Privacy Practices document.
Do we have your permission to:
Leave a message on your answering machine?

YesNo
Confirm appointments by leaving messages or speaking with family?

YesNo
Leave pre-medication reminders (if applicable)?

YesNo
Speak to household members concerning your care?

YesNo
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If the patient is a minor, please have parent/guardian sign below.
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