NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT
Rainbow Kids Clinic
111 Otis Smith Drive
Clarksville, TN 37043
I understand that, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:
I have received, read and understand your Notice of Privacy Practices containing a more complete description of the uses and disclosure of my health information. I understand that this organization has the right to change its Notice of Privacy Practices and that I may contact this organization at any time at the address above to obtain a current copy of the Notice of Privacy Practices.
I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or healthcare operations. I also understand you are not required to agree to me requested restrictions, but if you do not agree then you are bound to abide by such restrictions.
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111 Otis Smith Drive, Clarksville, Tennessee 37043 ♦ Phone: 931-553-6666 ♦ Fax 931.553.6681 ♦ Email: email@example.com