Policies, Consent, Submit Data
Please click on the blue links below, read carefully and sign your acceptance by
entering your First and Last Name in the boxes below.
Financial Policy / Medicare Acknowledgment
View
Financial Policy Form
Notice of Privacy
Practices
View Notice of Privacy
Practices Form
Patient Record Of Disclosure
The HIPAA privacy rule gives individuals the right to request a restriction on notes and
disclosure of their
Protected Health Information (PHI). The individual is also granted the right to request
confidential
communications, or that a communication be made by alternative means.
I wish to be contacted in the following manner: (Check ALL that apply)
I would prefer to be contacted on my:
I authorize you to discuss my medical history and release any and all medical
information to the following individuals.