NOTICE OF PRIVACY PRACTICES (HIPAA)

I understand that under the Health Insurance Portability & Accountability Act of 1996 (“HIPAA”) I have certain rights to privacy regarding my protected health information (PHI).  I understand that this information can and will be used to:

• Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in the treatment directly and indirectly.

• Obtain payment from third-party payers.

• Conduct normal healthcare operations such as quality assessments and physician certifications.

I received, read and understand your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my PHI.  I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time to obtain a current copy of the Notice of Privacy Practices.