Notice of Privacy Practices
ACKNOWLEDGEMENT FORM
Your privacy, including the confidentiality of your health information, is very important to us. Additionally, Federal law prohibits the unauthorized release of certain medical and health information. Before our office can use your Protected Heath Information for treatment, payment and health care operation you must acknowledge that you have received a copy of our notice of privacy practices information so you know how our office may use and disclose your Protected Health Information, You should carefully read our Notice of privacy Practices to understand how we take steps to protect the privacy and confidentiality of your Protected Health information. These rights include: (1) the right to request that we restrict how your Protected Health Information can be used or disclosed for treatment, payment or healthcare operations; (2) the right to receive confidential Communications of your Protected Health Information, if applicable; (3) the right to inspect and copy your Protected Health Information; (4) the right to amend your Protected Health Information; (5) the right to receive an accounting of the disclosures of your Protected Health Information.
By signing this form, you acknowledge that you have received a copy of our Notice of Privacy Practices concerning the use and disclosure of your Protected Health Information, by signing this form you acknowledge that you have received this information.
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Print Name /Relationship Signature- Patient or Guardian / Date
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Print Name /Relationship Signature- Patient or Guardian / Date
5945 Almaden Expressway #110
San Jose, CA 95120
408-997-1803