Trip 2 is committed to protecting your personal health information. We are required by law to maintain the privacy of health information that could reasonably be used to identify you, known as “protected health information” or “PHI.” We are also required by law to provide you with the attached detailed Notice of Privacy Practices (“Notice”) explaining our legal duties and privacy practices with respect to your PHI.
We respect your privacy, and treat all healthcare information about our patients with care under strict policies of confidentiality that our staff is committed to following at all times.
PLEASE READ THE ATTACHED DETAILED NOTICE. IF YOU HAVE ANY QUESTIONS ABOUT IT, PLEASE CONTACT Bob Beers, OUR HIPAA COMPLIANCE OFFICER, AT (305) 537-4150 or firstname.lastname@example.org.
Acknowledgement of receipt of Information Practices Notice (§164.520(a))
I,_______________________________, (patient’s name) understand that as part of my healthcare, this facility originates and maintains health records describing my health history, symptoms, examination and test results, diagnosis, treatment and any plans for future care or treatment. I acknowledge that I have been provided with and understand that this facility’s Notice of Privacy Practices provides a complete description of the uses and disclosures of my health information. I understand that:
Signature of Individual or Legal Representative Witness ___________________________________
Printed Name of Individual or Legal Representative ______________________________________
FOR OFFICE USE ONLY
We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but it could not be obtained because: