• We must provide you access to a Privacy Notice that explains how we may use or disclose your medical information.

We are dedicated to protecting your right to privacy of your medical information while providing the highest quality of medical care. We want you to be aware of new regulations that affect how we use and disclose your medical information, and the rights you have regarding your medical records. New Privacy Rules adopted as part of the Federal Health Insurance Portability and Accountability Act (HIPAA) establish standards for the release of medical information that personally identifies you.

Our Privacy Practices

• We will ask for you to acknowledge that you have received and understood our Privacy Notice.

Your Permission

• Once we have let you know about our Privacy Practices, we may release information about you for purposes of treatment, billing for services, or operational purposes without further permission from you.

Your Rights Regarding Your Medical Records

The Federal Privacy Regulations give you many rights regarding your medical records. They include:

• The right to an accounting of certain disclosures of your medical information in the six years prior to the date of your request.

• The right to inspect and obtain a copy of your medical information.

• The right to receive confidential communications of your medical information.

• The right to receive confidential communications by an alternative means at an alternative location.

• The right to request an amendment to your medical record.

• The right to submit a complaint to our Company about how your medical information is used or disclosed.

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Patient’s Signature                                                           Date