HIPAA Declaration 

The Practice: 
(a) Is required by federal law to  maintain the privacy of your PHI and to provide you with this Privacy Notice detailing the Practice's legal duties and privacy practices with respect to your PHI 
(b) Under the Privacy Rule, it may be required by State law to grant greater access or maintain greater restrictions on the use or release of your PHI than that which is provided for under federal law 
(c) Is required to abide by the terms of the Privacy Notice 
(d) Reserves the right to change the terms of this Privacy Notice and to make the new Privacy Notice provisions effective for all of your PHI that it maintains 
(e) Will distribute any revised Privacy Notice to you prior to implementation 
(f) Will not retaliate against you for filing a complaint 

Patient Communications: 
Health Insurance Privacy Act 1996 requires we inform you of the following government stipulations in order for 
us to contact you with educational and promotional items in the future via email, U.S. mail, telephone, and/or pre-
recorded messages. We WILL NOT ever share, sell, or “SPAM” your personal contact information. Marketing any communication about a product or service that encourages recipients to purchase or use the product or service. Communication can be defined as Voice Blasts, Email, and numerous marketing pieces. Communications to describe health-related products or services, or payment for them, provided by or included in a benefit plan of the covered entity making the communication. 

(a) Communications about participating providers in a provider or health plan network, replacement of or enhancements to a health plan, and health-related products or services available only to a health plan’s enrollees that add value to, but are not part of, the benefit plan. 

(b) Communication for treatment of the individual 

(c) Communications for case management or care coordination for the individual, or to direct or recommend alternative treatments, therapies, healthcare providers, or care settings to individuals PATIENT ACKNOWLEDGEMENT

I acknowledge receipt of this notice, and my understanding and my agreement to its terms. 

Patient Name: 	{PatientName}  (FirstName Lastname); {PatientSex} (in characters)
		{PatientID}    ( External ID); Born: {PatientDOB}   (yyy-mm-dd) 
Home Address: 	{Address}  (Example: street address only i.e. 1224 Oakdale Rd.)
Zip: 		{Zip}; City: {City}; State: {State}
Home Phone: 	{PatientPhone}  (output in this form: (000)000-0000)


		{PatientName}		        		Witnessed by: {ReferringDOC}
		Patient Signature: 			Witness Signature: 

		_________________________                      	_________________________ 

Date: {DOS}          (Date of service)

For Internal Use: 

Patient Refused to Sign: _______________________________  
Patient unable to sign for the following reason: _______________________________ 

I declare that today I have the following complaints: 
{ChiefComplaint}

I have suffered in the past and might still be suffering from:
{Allergies}

I  am aware that I have, have had the following Medical complaints:
{ProblemList}