Notice of Privacy Practices/Acknowledgment

You may fill out and submit this form on our Web site! Or, if you have concerns about providing information via the internet, print this form prior to an appointment. Then bring it with you to your first visit to save time when you arrive.

Maintaining privacy of your health information is very important to us. Attached you will find out Notice of Privacy Practices. The following is a brief summary of the content of the attached notice. We encourage you to read the entire Notice and ask any questions you have may have regarding its contents.

How We May Use and Disclose Health Information About You

This section describes the different ways we may use or disclose your health information without first obtaining a specific authorization from you. These types of uses and disclosures are specifically permitted by law because it is assumed you would want us to use or disclose your information for these purposes, or because such use or disclosure is recognized as critical to the functioning of our health care system.

Your Rights Regarding Youth Health Information

This section describes the following rights you have with respect to your health information and tells you how you may exercise these rights.
Right to inspect and copy
Right to request amendment
Right to an accounting of disclosures
Right to request restrictions on certain uses and disclosures
Right to request alternative means of communication
Right to receive a paper copy of our Notice of Privacy Practices

How to File Complaints Concerning Our Privacy Practices

This section tells you what you can do if you believe any of your rights have been violated. You will not be penalized for filing a complaint.

We ask you to acknowledge your receipt of this Notice by signing this form. You may request a copy of the Notice that follows. Also, the most current copy of our Notice will be posted in our office. If there are material changes to this Notice at a later date, you will be provided a copy of the revised Notice and asked to sign another acknowledgment.