Digital Communictions AckknowledgementOur Notice of Privacy Practices provides information about how we may use and disclose protected health information (PHI) about you.
We provide this form to comply with the Health Insurance Portability and Accountability Act (HIPAA). Please review the Notice of Privacy Practices thoroughly before signing this acknowledgement form.
If terms of our Notice change, a revised copy will be made available to you.
By signing this form, you acknowledge that our practice may use and disclose PHI about you for treatment, payment and healthcare operations.
You have the right to request that we restrict how PHI about you is used or disclosed for treatment, payment or healthcare operations.
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