SIMON GARZA JR., D.D.S.
2501 W. WILLIAM CANNON DR.
BUILDING
1,
Notice of Privacy Practices
Patient Acknowledgement
Patient
Name:_____________________________________ Date of Birth: ___________
I
have received this practice’s Notice of Privacy Practices written in plain
language. The Notice provides in detail
the
uses and disclosures
of my protected health information that may be made by this practice, my
individual rights and the
practice’s
legal duties with respect to my protected health information. The Notice includes:
·
A statement that
this practice is required by law to maintain the privacy of protected health
information.
·
A statement that
this practice is required to abide by the terms of the notice currently in effect.
·
Types of uses and
disclosures that this practice is permitted to make for each of the following
purposes: treatment,
payment, and health care operations.
·
A description of
each of the other purposes for which this practice is permitted or required to use
or disclose
protected health information without my written consent or
authorization.
·
A description of
uses and disclosures that are prohibited or materially limited by law.
·
A description of
other uses and disclosures that will be made only with my written authorization
and that I may
revoke such authorization.
·
My individual
rights with respect to protected health information and a brief description of
how I may exercise
these rights in relation to:
o The right to complain to this practice and to the Secretary
of HHS if I believe my privacy rights have been violated,
and that no retaliatory actions will be used against me
in the event of such a complaint.
o The right to request restrictions on certain uses and
disclosures of my protected health information, and that this
practice is not required to agree to a requested restriction.
o The right to receive confidential communications of
protected health information.
o The right to inspect and copy protected health
information.
o The right to amend protected health information.
o The right to receive an accounting of disclosures of
protected health information.
o The right to obtain a paper copy of the Notice of
Privacy Practices from this practice upon request.
This
practice reserves the right to change the terms of its Notice of Privacy
Practices and to make new provisions effective
for all protected
health information that it maintains. I
understand that I can obtain this practice’s current Notice of Privacy
Practices
on request.
Signature:______________________________________________ Date:_________________
Relationship to patient (If signed by a personal
representative of patient):____________________