NOTICE OF PRIVACY PRACTICES

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

Summary: By law, we are required to provide you with our Notice of Privacy Practices (NPP). This Notice describes how your medical information may be used and disclosed by us. It also tells how you can obtain access to this information.

As a patient, you have the following rights:

1.The right to inspect and copy your information.

2.The right to request corrections to your information.

3.The right to request that your information be restricted.

4.The right to request confidential communications.

5.The right to a report of disclosures of your information.

6.The right to a paper copy of this Notice.

We want to assure you that your medical/protected health information is secure with us. This Notice contains information about how we will insure that your information remains private.

If you have any questions about this Notice, the name and phone number of our contact person is listed on this page.

CONTACT PERSON: LEANN ELLENDER

PHONE NUMBER: (940)612-2020

ACKNOWLEDGEMENT OF NOTICE OF PRIVACY PRACTICES I hereby acknowledge that I have received a copy of this practice’s NOTICE OF PRIVACY PRACTICES. I understand that if I have questions or complaints regarding my privacy rights, that I may contact the person listed above. I further understand that the practice will offer me updates to this NOTICE OF PRIVACY PRACTICES should it be amended, modified, or changed in any way.

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Patient or Representative Name (please print)

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Patient or Representative Signature

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Date

___ Patient Refused to Sign.

___ Patient was unable to sign because ________________________________________.