Home » Patient Information » Notice of Privacy Practices Acknowledgement
I understand that, under the Health Insurance Portability
and Accountability Act of 1996 (HIPAA), I have a certain right to privacy regarding my Protected health information. I understand that the information can and will be use to:
I have reviewed, read the office’s Notice of Privacy Practices, posted in the lobby. I understand your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I understand that this organization has the right to change its Notice of Privacy Practice from time to time and that I may contact this organization at any time to obtain a current copy of Notice of Privacy Practices.
I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or healthcare operation. I also understand you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions.
2615 Southwest Frwy. Ste 290Houston, TX 77098-4608PH 713.523.8800F 713.523.8812
Mon 8:00 – 12:00Tue 1:30 – 5:00Wed 1:30 – 5:00Thr –Fri 8:00 – 12:00
12121 Richmond Ave.
Tue 8:00 – 12:00
Thr 1:30 – 5:00
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