North Coast Women’s Health
Acknowledgement of Receipt
of
To Our Patients,
The privacy of your health care information is
extremely important to us. We want you
to understand how we use and disclose your information and your rights to this
information. We ask you to review our
Notice of Privacy Practices that describes our legal duties with respect to
your health care information.
How we use health care information:
We use information about you to:
ü Provide
treatment to you
ü Ensure
appropriate payment for the treatment we provide, and
ü Monitor
the quality of our operations.
When we may disclose information:
In certain limited cases we are permitted to
disclose health care information about you.
Examples include when there is a serious threat to health or safety, for
worker’s compensation, to reduce public health risks, for health oversights and
in certain cases for law enforcement. In
addition, we may disclose information to tell you about health-related services
and alternative treatments, and to conduct health-related research with your
permission.
Your information rights:
We create a record of the care we give you.
ü You
have the right to know how we use your health information, who we can give it
to, and your rights to this information (Please see our Notice of Privacy
Practices.)
ü You
have the right to ask us to restrict uses and disclosures where we believe such
restrictions will not harm you and where it is possible for us to do so.
ü You
have the right to confidential communication of your health information. For example, you can ask for a conversation
to be held in private or for us to send a copy of your bill to a different
address.
ü You have the right to look at and get a copy
of information in our record unless your doctor has indicated this would be
harmful to you or someone else.
ü You
have the right to request that our records be amended if we agree it is
inaccurate or incomplete.
ü You
have a right to ask us for a list when we have disclosed your health
information to someone other than those treating you, handling your bills, for
our internal operation, or when you have authorized release of information.
Please sign below that you have received our Notice
of Privacy Practices. If you have any
questions, please speak to your provider or our practice manager at (707)
443-3557.
Signature:
_________________________________________ Date:
_________________
Print Name:
_______________________________________
Social Security Number: _____________________________
White
Copy: Chart
Yellow
Copy: Patient/Responsible Party pt
receipt of privacy notice.MS Word: 3/03