Privacy Practices

Step 3


Rainbow Kids Clinic
111 Otis Smith Drive
Clarksville, TN 37043
Fax 931-553-4006

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:

  • Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly.
  • Obtain payment from third-party payers.
  • Conduct normal healthcare operations such as quality assessments and physician certifications. 

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.

Continue to Office Policies           

111 Otis Smith Drive, Clarksville, Tennessee 37043 ♦ Phone: 931-553-6666 ♦ Fax 931.553.6681 ♦ Email: info@rainbowkidsclinic.com