|Patient name||Account #|
Acknowledgement of Receipt of Privacy Practices Policy
I have been presented with a copy of the Notice of Privacy Practices detailing how my health information may be used and disclosed as permitted under federal and state law and outlining my rights regarding my health information. 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 office at any time to obtain a current copy of the 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 healthcare providers who may be involved in that treatment directly and indirectly.
- Disclose your personal health information to designated family, friends, and others who are involved in your care.
- Conduct normal healthcare operations such as quality assessments and physician certifications.
- Allow this office to leave messages concerning my treatment on my personal answering systems.
I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment, or healthcare operations.
Authorization for Direct Payment
I assign payment of insurance benefits directly to Orthopedic Associates of Central CT for services provided by them. I understand I am financially responsible for any charges not covered.
Your electronic signature (full name typed in the following field) is legally binding.
I understand and agree to all of the above.
|Signature||Relationship to patient|