Model Notice of Privacy Practices for HIPAA Covered Health Care Provider | HHS.gov

I acknowledge that I have been provided with and given the opportunity to review the Practice's Notice of Privacy Practices in the link above. The Notice describes how my health information may be used and disclosed, my rights regarding my health information, and the Practice's responsibilities regarding the privacy of my information. I understand that I may request a copy of the Notice at any time.

I authorize the clinic and its associated health professionals to collect my personal and medical information as documented in this intake or any other medical notes or lab reports. In addition, I authorize the clinic and its associated health professionals to communicate with my family doctor and/or referring doctor as deemed necessary for my beneficial treatment. I also understand that my personal and medical information is confidential and will only be disclosed to third parties with my permission.

I understand that the practice may communicate with me regarding my care, appointments, billing, laboratory testing, and other practice-related matters through the patient portal, telephone, voicemail, email, or text messaging when appropriate.

I understand that although reasonable safeguards are used to protect my information, standard email and text messaging may not always be fully secure and carry some risk of unauthorized access. I understand that I should use the secure patient portal for sensitive medical information whenever available.

I authorize the practice to contact me using the telephone number and email address I provide for purposes related to my care and the administration of my healthcare services. I understand that I may request changes to my communication preferences at any time.

My health information will be maintained and disclosed in accordance with applicable privacy laws and the practice's Notice of Privacy Practices.