Notice of Privacy Practices

IMPORTANT: 
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.  PLEASE REVIEW IT CAREFULLY.

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 bbeers@trip2.com.

HIPAA Privacy Rule

Receipt of Notice of Privacy Practices 

Written Acknowledgement Form

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: 

  • I have the right to review this facility ‘s Notice of Privacy Practices prior to signing this acknowledgement 
  • This facility reserves the right to change their Notice of Privacy Practices and prior to implementation of this will mail a copy of any revised notice to the address I've provided if requested. 

Signature of Individual or Legal Representative Witness ___________________________________

Printed Name of Individual or Legal Representative ______________________________________ 

Date: ________________

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: 

  • Individual refused to sign 
  • Communication barrier prohibited obtaining the acknowledgement 
  • An emergency situation prevented us from obtaining acknowledgement 
  • Others (please specify) 
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