HIPAA Form

I understand that, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:

• Conduct, plan, and direct my treatment and follow-up among the multiple
• Obtain payment for third-party prayers
• Conduct normal healthcare operations such as quality assessment and physician certification

I acknowledge that I have received your Notice of Privacy Practices concerning the uses and disclosures of my health information. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time at the address above to obtain a current copy of the 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 health care operation. also understand that you are not required to agree to my requested restrictions, but if you do agree to them, you are bound to abide by such restrictions.