ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

I understand that under the Health Insurance Portability and 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 for the following:

● To conduct, plan, and direct my treatment and follow-up among multiple healthcare providers who may be involved in that treatment, directly and indirectly.

● To obtain payment from third-party payers, including use as a means by which an insurance or other payer can verify that services billed were actually provided.

● To conduct normal healthcare operations such as quality assessments and reviewing physician competence for physician certifications.

I have been provided with Hilltop Medical Clinic’s Notice of Privacy Practices, which document contains a more complete description of the uses and disclosures of my health information. I understand that Hilltop Medical Clinic has the right to change its Notice of Privacy Practices from time to time and that I may contact Hilltop Medical Clinic at any time at the address above and obtain a current copy of the Notice of Privacy Practices. In addition, Hilltop Medical Clinic will post a copy of any revised Notice of Privacy Practices in its lobby for my review.

I understand:

● I may request in writing that Hilltop Medical Clinics restrict how my private information is used or disclosed to carry out treatment, payment, or healthcare operations. I also understand that Hilltop Medical Clinic is not required to agree to my requested restrictions, but if Hilltop Medical Clinic does agree it is bound to abide by such restrictions.

● I have the right to review the notice prior to signing this Acknowledgement, and also the right to revoke this Acknowledgement in writing except to the extent that Hilltop Medical Clinics have already taken action in reliance thereon.

● I personally must sign a medical records release authorization before my specific health information will be released to anyone by Hilltop Medical Clinic.

● I may refuse to sign this consent Form. However, if I do so, Hilltop Medical Clinic is NOT required to see and/or treat me as a patient.

If you request restrictions on the use or disclosure of your health information, you must verbally notify the receptionist to make the appropriate documentation.

I attempted to obtain the patient’s signature in acknowledgment of receipt of the Notice of Privacy Practices, but was unable to do so as documented below:

Date:_____________ Initials:_______Reason:____________________________________

Effective Date:1/1/2016

Once you have signed this agreement, you agree to all the terms and conditions contained herein and the agreement will be in full force and effect.