ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
You are not required to take this Notice and you may return it to us, if you wish. However, as a patient, you are asked to acknowledge receipt of the Notice by signing this Acknowledgement of Receipt of Notice of Privacy Practices (“Acknowledgement”).
Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), we are required to furnish you with a copy of the Notice and make it available to you for subsequent inspection. We are also required to provide this Acknowledgement for your signature. This Acknowledgement does not contain the Notice, it only confirms that you have received the Notice. You are not required to sign this Acknowledgement, though we are required to note in our files any refusal you might indicate to sign this Acknowledgement.
• I have received and reviewed NYC Medical Practice, P.C. d/b/a Goals Plastic Surgery’s Notice of Privacy Practices, which is written in plain language and contains a detailed explanation of:
- Uses and disclosures of my personal health information by NYC Medical Practice, P.C. d/b/a Goals Plastic Surgery;
- My individual rights with regard to those disclosures; and
- My choices regarding how my health information is used and shared.
• I understand that I am entitled to keep the copy of the Notice of Privacy Practices that was provided to me.
CONSENT FOR EVALUATION AND/OR TREATMENT
By signing below, I am giving my consent to NYC Medical Practice, P.C. d/b/a Goals Plastic Surgery for evaluation and/or treatment. Once I have been examined, I understand that I will be informed of any medical or cosmetic recommended procedures and/or treatments and given the option to accept or decline.