Acknowledgment of Receipt of Notice of Privacy Practices
Right Place Health is committed to protecting the privacy and confidentiality of your health information.
Our Notice of Privacy Practices explains:
How we may use and disclose your protected health information (PHI)
Your privacy rights under federal law
How you may access or request corrections to your medical record
How to request restrictions on certain disclosures
How to file a privacy complaint if you believe your rights have been violated
A copy of our Notice of Privacy Practices is available:
Through the FollowMyHealth patient portal
On our website
In our office upon request
Acknowledgment
By signing below, I acknowledge that:
I acknowledge that I have received, or have been offered the opportunity to receive, the Right Place Health Notice of Privacy Practices.
I understand that the Notice explains how my protected health information may be used and disclosed.
I understand that I may request a copy of the Notice at any time.
I understand that signing this acknowledgment does not waive any of my privacy rights under federal or state law.
Questions
If I have questions about my privacy rights or how my health information is used, I understand that I may contact Right Place Health for additional information.
Consent
I have read this Consent for Treatment, or it has been explained to me. I understand its contents, have had an opportunity to ask questions, and voluntarily consent to receive healthcare services from Right Place Health.
Person Completing this Form (Required)
☐I am the patient
☐I am a helper assisting the patient complete this form
☐I am a Legal Representative of this patient (I have completed the Legal Representative form)
Signature of Patient or Responsible Party
_________________________________________________________