Notice of Privacy Practices

Health Insurance Portability and Accountability Act

Notice of Privacy Practices

This is to verify and declare that The Jupiter Preventive Medicine Center/Drug Study Institute has made available for my review the HIPAA (Health Insurance Portability and Accountability Act of 1996) on their website and I specifically read about:

PHI (Protected Health Information).
The Use and Disclosure of Protected Health Information in Treatment, Payment, and Health Care Operations.
Additional Uses and Disclosures Permitted Without Authorization or An Opportunity to Object.
Uses and Disclosures Permitted With An Opportunity to Object.
Uses and disclosures Authorized by You.
Your Rights.
The Duties of The Jupiter Preventive Medicine Center/Drug Study Institute.
Complaints.
Contact Person.
Effective Date.

Acknowledgement of Notice of Privacy Practices
"I hearby 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."

_________________________________________________________
Patient or Representative Name (please print)

_________________________________________________________
Patient or Representative Signature

_________________________________________________________
Date

_________ Patient refused to sign

_________ Patient was unable to sign because

_________________________________________________________