ABA INTAKE FORM CHILD INFORMATION. Today s Date: / / Child s name: DOB: Address: City: State: Zip Phone:

Save this PDF as:
 WORD  PNG  TXT  JPG

Size: px
Start display at page:

Download "ABA INTAKE FORM CHILD INFORMATION. Today s Date: / / Child s name: DOB: Address: City: State: Zip Phone:"

Transcription

1 Today s Date: / / ABA INTAKE FORM CHILD INFORMATION Child s name: DOB: Address: City: State: Zip Phone:

2 FAMILY INFORMATION Mother s/guardian s name: Work #: Occupation: Address (if different from client): City: State: Zip address: Father s/guardian s name: Work #: Occupation: Address (if different from client): City: State: Zip address: Marital status of parents: Married Separated Divorced Single Parent(s) with Custody of Child: Was child adopted? Yes No FAMILY INFORMATION (CON T) Siblings Name: Age: Name: Age: Name: Age: Family history of developmental disability or mental illness? Yes No Condition: Relation to client: Condition: Relation to client: Revised 2/18/15 1

3 SCHOOL INFORMATION School district: Name of school: Grade: Date enrolled: Date of recent IEP: Placement: Inclusion/General Ed Mainstream SDC Non-public school Days and times of attendance: RELATED SERVICES Current and past services received (e.g., ABA, OT, SLP) Service/Therapy: School Home Provider: Dates of service: FROM TO Agency address: Phone: May we contact? Yes No Hours per week Service/Therapy: School Home Provider: Dates of service: FROM TO Agency address: Phone: May we contact? Yes No Hours per week Revised 2/18/15 2

4 Service/Therapy: School Home Provider: Dates of service: FROM TO Agency address: Phone: May we contact? Yes No Hours per week Progress observed: Revised 2/18/15 3

5 MEDICAL HISTORY Physician: Phone: Is your child currently taking medication? Yes No Medication 1). Dosage: Administration Times: Used for: 2). Dosage: Administration Times: Used for: 3). Dosage: Administration Times: Used for: Are there concerns about your child s hearing? Yes No Hearing assessment conducted? Yes No Are there concerns about your child s vision? Yes No Hearing assessment conducted? Yes No Any childhood illnesses? DEVELOPMENTAL HISTORY What age did your child: Sit up independently: Crawl: Walk: Eat solids: Sleep through the night: Revised 2/18/15 4

6 At what age did you suspect problems about your child s development? Has your child exhibited any loss of skills in any area? Yes No If so, please explain SOCIAL AND PLAY SKILLS Describe how your child plays: Does your child play independently? Yes No If so, for how long? With what items/toys? Does your child play with toys appropriately? Yes No Explain: Does your child attempt to involve others in play? Yes No Explain: Does your child engage in interactive play with other children? Yes No Explain: Does your child attempt to involve others in play? Yes No Explain: Does your child engage in pretend play? Yes No Explain: COMMUNICATION SKILLS Describe your child s spontaneous vocalization/language: Revised 2/18/15 5

7 Does your child respond in some way when his/her name is called? Describe your child s ability to imitate sounds, words, phrases: Describe how your child communicates what she/he wants: Does your child follow simple directions Yes No If so, how consistently? Does your child make eye-contact? Yes No If so, how consistently? Does your child label items/events/actions? Yes No If so, how many? When? Does your child answer WH questions? Yes No If so, how many? When? Does your child engage in verbal exchanges with others? Yes No If so, how many? When? Revised 2/18/15 6

8 ACADEMIC SKILLS Can your child perform any of the following? Identify numbers: Yes No Identify letters: Yes No Complete puzzle: Yes No If so, what kind? Match items: Yes No Sort colors and shapes: Yes No Stack blocks: Yes No Draw: Yes No Write numbers/letters: Yes No Identifies people: Yes No MOTOR SKILLS Can your child imitate simple gestures (e.g., clapping, waving)? Yes No Can your child imitate simple gestures using objects (e.g., banging on drum)? Yes No Can your child imitate fine motor gestures? Yes No Describe the child s general gross motor abilities: Describe the child s general fine motor abilities: SELF HELP SKILLS Is your child toilet trained? Yes No How does your child feed him/herself? Does your child dress him/herself independently? Yes No Does your child clean up after him/herself independently? Yes No BEHAVIORS OF CONCERN Have you observed your child emit any of these behaviors? * Self-stimulatory behaviors (examples: vocal sounds, flapping hands, lining up objects): Yes No If yes, please explain: * Self-injurious behaviors (examples: banging head on hard objects, eye-poking): Yes No If yes, please explain: Revised 2/18/15 7

9 * Unsafe behaviors to self (examples: running away, climbing furniture): Yes No If yes, please explain: * Unsafe behaviors to others (examples: hitting, throwing objects): Yes No If yes, please explain: * Ritualistic/Obsessive behaviors (examples: wearing same clothes every day, talks only about one topic): Yes No If yes, please explain: * Other behaviors of concern: Frequency recommendations: *Please attach assessments or evaluations that may help in developing your child s program Revised 2/18/15 8

10 FOREVER HOPE COUNSELING & EDUCATIONAL SERVICES, LLC Notice of Privacy Practices for Protected Health Information Effective Date: February 10, 2015 This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully! We are permitted by federal privacy laws to make uses and disclosures of your health information for purposes of treatment, payment and health care operations. Protected health information is the information we create and obtain in providing our services to you. Such information may include documenting your symptoms, behaviors, examination and test results, diagnoses, treatment, and applying for future care or treatment. It also includes billing documents for those services. Examples of Uses of Your Health Information for Treatment Purposes are: A behavior analyst may use your health information to provide you with services. A behavior analyst may obtain treatment information about you and record it in your client file. During the course of your treatment, the behavior analyst may need to consult with other professionals or individuals (e.g., physicians, social workers, educators, family members etc.,) involved in your medical care or treatment. He/she will obtain authorization to share your personal information with these individuals. Your health information may be shared with other clinical staff in the company for additional support in developing your treatment program. Example of Use of Your Health Information for Payment Purposes: We submit requests for payment to your health insurance company. The health insurance company (or other agencies/businesses helping us obtain payment) requests information from us regarding medical care given. We will provide information to them about you and the services provided. Example of Use of Your Information for Health Care Operations: We obtain services from our insurers or other business associates such as quality assessment, quality improvement, outcome evaluation, protocol and clinical guideline development, training programs, credentialing, medical review, legal services, and insurance. We will share HIPAA Privacy Notice

11 information about you with such insurers or other business associates as necessary to obtain these services. Example of Use of Your Information for Fundraising Activities: We may contact you as part of a fundraising effort. We may use health information about you to contact you in an effort to raise money for our company and its operations. We may disclose health information to a foundation related to us so that the foundation may contact you in raising money for our office/hospital. We only would release contact information, such as your name, address and phone number, and the dates you received treatment or services at our office/hospital. If you do not want us to contact you for fundraising efforts, you must notify our Director in writing. Your Health Information Rights The health and billing records we maintain are the physical property of Forever Hope Counseling & Educational Services, LLC. The information in it, however, belongs to you. You have a right to: Request a restriction on certain uses and disclosures of your health information by contacting our office -- we are not required to grant the request, but we will comply with any request granted; Request a restriction on disclosures of medical information to a health plan for purposes of carrying out payment or health care operations (and is not for purposes of carrying out treatment; and the PHI pertains solely to a health care service for which the provider has been paid out of pocket in full we must comply with this request; Obtain a paper copy of the current Notice of Privacy Practices for Protected Health Information ("Notice") by making a request at our office; Request that you be allowed to inspect and copy your health record and billing record you may exercise this right by contacting our office; Appeal a denial of access to your protected health information, except in certain circumstances; Request that your health care record be amended to correct incomplete or incorrect information by delivering a request to our office. We may deny your request if you ask us to amend information that: Was not created by us, unless the person or entity that created the information is no longer available to make the amendment; HIPAA Privacy Notice

12 Is not part of the health information kept by or for the office; Is not part of the information that you would be permitted to inspect and copy; or, Is accurate and complete. If your request is denied, you will be informed of the reason for the denial and will have an opportunity to submit a statement of disagreement to be maintained with your records; Request that communication of your health information be made by alternative means or at an alternative location by delivering the request in writing to our office; Obtain an accounting of disclosures of your health information as required to be maintained by law by delivering a request to our office. An accounting will not include uses and disclosures of information for treatment, payment, or operations; disclosures or uses made to you or made at your request; uses or disclosures made pursuant to an authorization signed by you; uses or disclosures made in a facility directory or to family members or friends relevant to that person's involvement in your care or in payment for such care; or, uses or disclosures to notify family or others responsible for your care of your location, condition, or your death. Revoke authorizations that you made previously to use or disclose information by delivering a written revocation to our office, except to the extent information or action has already been taken. If you want to exercise any of the above rights, please make an appointment with our Director at (210) to make a request in person or in writing, during regular, business hours. She will inform you of the steps that need to be taken to exercise your rights. The office is required to: Our Responsibilities Maintain the privacy of your health information as required by law; Provide you with a notice as to our duties and privacy practices as to the information we collect and maintain about you; Abide by the terms of this Notice; Notify you if we cannot accommodate a requested restriction or request; and, HIPAA Privacy Notice

13 Accommodate your reasonable requests regarding methods to communicate health information with you. We reserve the right to amend, change, or eliminate provisions in our privacy practices and access practices and to enact new provisions regarding the protected health information we maintain. If our information practices change, we will amend our Notice. You are entitled to receive a revised copy of the Notice by calling and requesting a copy of our "Notice" or by visiting our office and picking up a copy. To Request Information or File a Complaint If you have questions, would like additional information, or want to report a problem regarding the handling of your information, you may contact Sandra Salazar, Director, (210) Additionally, if you believe your privacy rights have been violated, you may file a written complaint at our office by mailing the written complaint to Hardy Oak Suite 104, San Antonio, TX We cannot, and will not, require you to waive the right to file a complaint as a condition of receiving treatment from Forever Hope Counseling & Educational Services, LLC. We cannot, and will not, retaliate against you for filing a complaint. Communication with Family Other Disclosures and Uses Using our best judgment, we may disclose to a family member, other relative, close personal friend, or any other person you identify, health information relevant to that person's involvement in your care or in payment for such care if you do not object or in an emergency. Public Health As authorized by law, we may disclose your protected health information to public health or legal authorities charged with preventing or controlling disease, injury, or disability; to report reactions to medications or problems with products; to notify people of recalls; to notify a person who may have been exposed to a disease or who is at risk for contracting or spreading a disease or condition. Abuse & Neglect HIPAA Privacy Notice

14 We may disclose your protected health information to public authorities as allowed by law to report abuse or neglect. Law Enforcement We may disclose your protected health information for law enforcement purposes as required by law, such as when required by a court order, or in cases involving felony prosecution, or to the extent an individual is in the custody of law enforcement. Judicial/Administrative Proceedings We may disclose your protected health information in the course of any judicial or administrative proceeding as allowed or required by law, with your authorization, or as directed by a proper court order. Serious Threat To avert a serious threat to health or safety, we may disclose your protected health information consistent with applicable law to prevent or lessen a serious, imminent threat to the health or safety of a person or the public. For Specialized Governmental Functions We may disclose your protected health information for specialized government functions as authorized by law such as to Armed Forces personnel, for national security purposes, or to public assistance program personnel. Other Uses Other uses and disclosures, besides those identified in this Notice, will be made only as otherwise required by law or with your written authorization and you may revoke the authorization as previously provided in this Notice under "Authorization for Disclosure". HIPAA Privacy Notice

15 Forever Hope Counseling & Educational Services, LLC Name of Client: Client Date of Birth: Notice of Privacy Practices Acknowledgement I acknowledge that I have received a copy of the Notice of Privacy Practices. Signature of Client/Client Representative Date Relationship to Client Documentation of Good Faith Efforts To obtain client s acknowledgment that they received provider s Notice of Privacy Practices (For use when acknowledgment cannot be obtained from the Client.) On / /, the client was provided with a copy of Notice of Privacy Practices. A good faith effort was made to obtain from the client a written acknowledgment of his/her receipt of the Notice. However, such acknowledgement was not obtained because: Client refused to sign. Client was unable to sign or initial because: The client had a medical emergency, and an attempt to obtain the acknowledgment will be made at the next available opportunity. Other reason (describe below): Signature of Employee Completing Form: Date Signed: August 2011

16 HIPAA Privacy Notice Acknowledgement Informed Consent and Service Agreement I,, give my consent for Forever Hope Counseling & Educational Services, LLC to provide behavior analytic services to my child,, in accordance with the ethical guidelines proposed by the Behavior Analytic Certification Board (BACB). I also understand that I may withdraw my consent and terminate treatment at anytime and for any reason. I understand that any information provided in this intake as well as any information obtained at any point during the interview process or course of treatment, is kept strictly confidential in accordance with HIPAA regulation guidelines and the law. I understand that state laws may require that confidentiality be broken under certain circumstances, specifically, if I am judged by the behavior analyst to be of danger to myself and/or others, gravely disabled, or if there is suspected child abuse. I understand that Board Certified Behavior Analysts are bound to strict ethical guidelines of practice and that any issues of concern that may arise throughout the treatment process that are out of the behavior analyst s area of experience may result in referrals to a more appropriate agency or individual. Signature of Parent or Guardian Date Witness Date

17 Payment Policy I,, agree to pay Forever Hope Counseling & Educational Services, LLC for all services rendered and agree to abide by the following guidelines: 1. Payment. I understand I will prepay on a: weekly biweekly or on a monthly basis for all services rendered me by Forever Hope Counseling & Educational Services, LLC. Cash, credit or check will be accepted. I also understand there is 3% charge for credit card payments; this includes payments made over the phone. 2. Insurances. I also understand I am responsible for any claims that need to be submitted to my insurance for possible reimbursement. If I am receiving funding from an outside funding source or agency, the funding source or agency may be billed directly for the services. 3. Nonpayment. If my account is over 10 days past due, I will receive a letter stating to pay my account in full and all services will be cancelled until full payment has been paid. Please be aware that if a balance remains unpaid, we may refer your account to a collection agency. 4. Returned check/insufficient funds. I understand I will be charged a fee of $35 for any returned checks. 5. Missed appointments. In the event of emergency situations, I must provide 24 hours notice to my primary contact person at Forever Hope Counseling & Educational Services, LLC in order to cancel an appointment or I will be billed for the full amount of the session. In the event of an unexpected illness in which 24 hours notice cannot be made, I am required to provide at least a 2 hours notice prior to the start of a scheduled appointment in order to prevent being billed for the full session. I understand that when a client arrives late to a scheduled appointment, the client is billed the rate of the full appointment and that the remainder of the session time will be offered. Repeated cancellations or failures to keep scheduled sessions or frequently arriving late to scheduled sessions will result in termination of services. I have read and understand the payment policy: Signature of client or guardian Date

EARLY INTERVENTION SERVICES INTAKE PACKET

EARLY INTERVENTION SERVICES INTAKE PACKET EARLY INTERVENTION SERVICES INTAKE PACKET Intake Form (complete all parts) Notice of Privacy Practices (keep) Notice of Privacy Practices Acknowledgement (sign) Informed Consent and Service Agreement (do

More information

Notice of Privacy Practices for Protected Health Information (PHI)

Notice of Privacy Practices for Protected Health Information (PHI) Notice of Privacy Practices for Protected Health Information (PHI) Arapahoe Sports Medicine and Rehabilitation THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW

More information

Metropolitan Living, LLC 151 W. Burnsville Parkway, Suite 101 Burnsville, MN 55337 Ph: (952) 564-3030 Fax: (651) 925-0031

Metropolitan Living, LLC 151 W. Burnsville Parkway, Suite 101 Burnsville, MN 55337 Ph: (952) 564-3030 Fax: (651) 925-0031 The Health Insurance Portability and Accountability Act (HIPAA) and Client Privacy Statement This notice describes how your medical information may be used and disclosed and how you can get access to this

More information

Sarasota Personal Medicine 1250 S. Tamiami Trail, Suite 202 Sarasota, FL 34239 Phone 941.954.9990 Fax 941.954.9995

Sarasota Personal Medicine 1250 S. Tamiami Trail, Suite 202 Sarasota, FL 34239 Phone 941.954.9990 Fax 941.954.9995 Sarasota Personal Medicine 1250 S. Tamiami Trail, Suite 202 Sarasota, FL 34239 Phone 941.954.9990 Fax 941.954.9995 NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY

More information

Patterson Dental Supply, Inc. Sample HIPAA Notice of Privacy Practices for its Dental Practice Customers. Last Updated April 1, 2010

Patterson Dental Supply, Inc. Sample HIPAA Notice of Privacy Practices for its Dental Practice Customers. Last Updated April 1, 2010 Patterson Dental Supply, Inc. Sample HIPAA Notice of Privacy Practices for its Dental Practice Customers Last Updated April 1, 2010 This sample HIPAA Notice of Privacy Practices is being provided by Patterson

More information

SOUTHLAKE DERMATOLOGY 1170 N. Carroll Ave. Southlake, TX 76092 www.southlakedermatology.com Main 817-251-6500 Fax 817-442-0550

SOUTHLAKE DERMATOLOGY 1170 N. Carroll Ave. Southlake, TX 76092 www.southlakedermatology.com Main 817-251-6500 Fax 817-442-0550 THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. EFFECTIVE September 15, 2014 This Notice of

More information

650 Clark Way Palo Alto, CA 94304 650.326.5530

650 Clark Way Palo Alto, CA 94304 650.326.5530 THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. (Adopted 4-14-03; revised December 2006) If

More information

GONZABA MEDICAL GROUP PATIENT REGISTRATION FORM

GONZABA MEDICAL GROUP PATIENT REGISTRATION FORM GONZABA MEDICAL GROUP PATIENT REGISTRATION FORM DATE: CHART#: GUARANTOR INFORMATION LAST NAME: FIRST NAME: MI: ADDRESS: HOME PHONE: ADDRESS: CITY/STATE: ZIP CODE: **************************************************************************************

More information

IF YOU HAVE ANY QUESTIONS ABOUT THIS NOTICE OR IF YOU NEED MORE INFORMATION, PLEASE CONTACT OUR PRIVACY OFFICER:

IF YOU HAVE ANY QUESTIONS ABOUT THIS NOTICE OR IF YOU NEED MORE INFORMATION, PLEASE CONTACT OUR PRIVACY OFFICER: NOTICE OF PRIVACY PRACTICES COMPLETE EYE CARE THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED OR DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

More information

NORTHSTAR DERMATOLOGY, PA NOTICE OF PRIVACY PRACTICES

NORTHSTAR DERMATOLOGY, PA NOTICE OF PRIVACY PRACTICES NORTHSTAR DERMATOLOGY, PA NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT

More information

Garland s Christian Counseling Center

Garland s Christian Counseling Center Garland s Christian Counseling Center : PERSONAL DATA Name: Email: Home Phone: Address: Cell Phone: Work Phone: (Street, City, Zip Code) DL #, ST & Exp : SS#: DOB: Sex: Please circle where we may leave

More information

INTEGRITY WELLNESS CENTER NOTICE OF PRIVACY PRACTICES

INTEGRITY WELLNESS CENTER NOTICE OF PRIVACY PRACTICES INTEGRITY WELLNESS CENTER NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YU CAN GET ACCESS TO THIS INFORMATION- PLEASE REVIEW IT CAREFULLY

More information

MULTICARE ASSOCIATES OF THE TWIN CITIES, P.A. NOTICE OF PRIVACY PRACTICES

MULTICARE ASSOCIATES OF THE TWIN CITIES, P.A. NOTICE OF PRIVACY PRACTICES MULTICARE ASSOCIATES OF THE TWIN CITIES, P.A. NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

More information

HIPAA PRIVACY NOTICE PLEASE REVIEW IT CAREFULLY

HIPAA PRIVACY NOTICE PLEASE REVIEW IT CAREFULLY HIPAA PRIVACY NOTICE THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN OBTAIN ACCESS TO THIS INFORMATION. INTRODUCTION PLEASE REVIEW IT CAREFULLY Moriarty

More information

APPLETREE PEDIATRICS, PA NOTICE OF PRIVACY PRACTICES

APPLETREE PEDIATRICS, PA NOTICE OF PRIVACY PRACTICES APPLETREE PEDIATRICS, PA NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

More information

NOTICE OF PRIVACY PRACTICES

NOTICE OF PRIVACY PRACTICES NOTICE OF PRIVACY PRACTICES The Pain Treatment Center, Inc. d/b/a Stone Road Surgery Center THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS

More information

NOTICE OF PRIVACY PRACTICES FOR OUR PATIENTS POTOMAC PHYSICIAN ASSOCIATES, P.C.

NOTICE OF PRIVACY PRACTICES FOR OUR PATIENTS POTOMAC PHYSICIAN ASSOCIATES, P.C. NOTICE OF PRIVACY PRACTICES FOR OUR PATIENTS POTOMAC PHYSICIAN ASSOCIATES, P.C. THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED OR DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

More information

DALLAS ALLERGY & ASTHMA CENTER

DALLAS ALLERGY & ASTHMA CENTER DALLAS ALLERGY & ASTHMA CENTER Gary N. Gross, MD Michael E. Ruff, MD 5499 Glen Lakes Dr., Suite 100 Dallas, TX 75231 Dania A. Wierzbicki, MD Phone: (214) 691-1330 Jane Zepeda, PA-C FAX: (214) 691-6405

More information

NOTICE OF PRIVACY PRACTICES ILLINOIS EYE CENTER

NOTICE OF PRIVACY PRACTICES ILLINOIS EYE CENTER NOTICE OF PRIVACY PRACTICES ILLINOIS EYE CENTER THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED OR DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

More information

Policy & Procedure AUTUMN RIDGE RESIDENTIAL CARE. March, 2013

Policy & Procedure AUTUMN RIDGE RESIDENTIAL CARE. March, 2013 AUTUMN RIDGE RESIDENTIAL CARE Policy & Procedure HIPAA / PRIVACY NOTICE OF PRIVACY PRACTICES FUNCTION NUMBER PRIOR ISSUE EFFECTIVE DATE March, 2013 PURPOSE To ensure that a Notice of Privacy Practices

More information

Notice of Privacy Practices

Notice of Privacy Practices Notice of Privacy Practices This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully. This Notice of

More information

Dr. Adam Apfelblat 5140 Highland Road Waterford 48327 Phone: (248)618-3467 Fax: (248)618-3515

Dr. Adam Apfelblat 5140 Highland Road Waterford 48327 Phone: (248)618-3467 Fax: (248)618-3515 Dr. Adam Apfelblat 5140 Highland Road Waterford 48327 HIPAA NOTICE OF PRIVACY PRACTICES PLEASE REVIEW THIS NOTICE CAREFULLY. IT DESCRIBES HOW YOUR MEDICAL INFORMATION MAY BE USED AND DISCLOSED AND HOW

More information

HIPAA Notice of Patient Privacy Practices

HIPAA Notice of Patient Privacy Practices HIPAA Notice of Patient Privacy Practices Effective Date: January 1, 2014 THIS NOTICE DESCRIBES HOW PROTECTED HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

More information

Notice of Privacy Practices. Human Resources Division Employees Benefits Section

Notice of Privacy Practices. Human Resources Division Employees Benefits Section Notice of Privacy Practices Human Resources Division Employees Benefits Section THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

More information

ADULT REGISTRATION FORM. Last Name First Name Middle Initial. Date of Birth Age Identified Gender. Street Address. City State Zip Code

ADULT REGISTRATION FORM. Last Name First Name Middle Initial. Date of Birth Age Identified Gender. Street Address. City State Zip Code ADULT REGISTRATION FORM Last Name First Name Middle Initial Date of Birth Age Identified Gender Street Address City State Zip Code Home Phone Cell Phone FINANCIALLY RESPONSIBLE PARTY (If different from

More information

LAWRENCE COUNTY MEMORIAL HOSPITAL Lawrenceville, Illinois. NOTICE OF PRIVACY PRACTICES Effective April 14, 2003 Revised May, 2013

LAWRENCE COUNTY MEMORIAL HOSPITAL Lawrenceville, Illinois. NOTICE OF PRIVACY PRACTICES Effective April 14, 2003 Revised May, 2013 LAWRENCE COUNTY MEMORIAL HOSPITAL Lawrenceville, Illinois NOTICE OF PRIVACY PRACTICES Effective April 14, 2003 Revised May, 2013 THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU WILL BE USED AND

More information

Effective Date of This Notice: September 1, 2013

Effective Date of This Notice: September 1, 2013 Rev.10-2013-KB P-drive-HR Forms NOTICE OF HEALTH INFORMATION PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED OR DISCLOSED BY United Cerebral Palsy of Miami (UCP) and

More information

PRIVACY POLICY (IN ACCORDANCE WITH HIPAA)

PRIVACY POLICY (IN ACCORDANCE WITH HIPAA) PRIVACY POLICY (IN ACCORDANCE WITH HIPAA) The privacy of your medical information is important to us. We understand that your medical information is personal and we are committed to protecting it. This

More information

Intake for Services. Birth date: Age: Gender: Name of Spouse: Years Married: Spouse's Age:

Intake for Services. Birth date: Age: Gender: Name of Spouse: Years Married: Spouse's Age: Intake for Services Today's Date Last name: First name: Birth date: Age: Gender: Address: City/State/Zip Email: Home Phone: Cell phone: Marital Status: No. of Children & ages: If presently married: Name

More information

NOTICE OF PRIVACY PRACTICE

NOTICE OF PRIVACY PRACTICE Effective Date: September 23, 2013 NOTICE OF PRIVACY PRACTICE UNIVERSITY OF CALIFORNIA SAN FRANCISCO UCSF HEALTH SYSTEM THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED

More information

GENOA, a QoL HEALTHCARE COMPANY, LLC WEBSITE PRIVACY POLICY

GENOA, a QoL HEALTHCARE COMPANY, LLC WEBSITE PRIVACY POLICY GENOA, a QoL HEALTHCARE COMPANY, LLC WEBSITE PRIVACY POLICY PLEASE READ THIS WEBSITE PRIVACY POLICY CAREFULLY BEFORE USING THIS WEBSITE, OR SUBMITTING ANY PROTECTED HEALTH INFORMATION OR PERSONALLY IDENTIFIABLE

More information

NOTICE OF PRIVACY PRACTICES

NOTICE OF PRIVACY PRACTICES NOTICE OF PRIVACY PRACTICES In 1996, the U.S. Congress passed the Health Insurance Portability and Accountability Act (HIPAA). Among others, the Act applies to health care providers and hospitals; it is

More information

NOTICE OF PRIVACY PRACTICES

NOTICE OF PRIVACY PRACTICES NOTICE OF PRIVACY PRACTICES Effective Date: Immediately This information is made available to all patients THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU

More information

BRAIN PERFORMANCE & PSYCHOLOGY CENTER NOTICE OF PRIVACY PRACTICES

BRAIN PERFORMANCE & PSYCHOLOGY CENTER NOTICE OF PRIVACY PRACTICES BRAIN PERFORMANCE & PSYCHOLOGY CENTER NOTICE OF PRIVACY PRACTICES Effective Date: 10-20-2014 THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS

More information

Information with a person who is involved in your medical care or payment for your care, such as your family or a

Information with a person who is involved in your medical care or payment for your care, such as your family or a Notice of Privacy Practices Effective Date: September 23, 2013 THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW

More information

Northwest Cardiology Associates 400 W. Northwest Hwy Barrington, IL 60010 847.382.4600 Fax 847.382.1771. HIPAA Notice of Privacy Practices ( Notice )

Northwest Cardiology Associates 400 W. Northwest Hwy Barrington, IL 60010 847.382.4600 Fax 847.382.1771. HIPAA Notice of Privacy Practices ( Notice ) Northwest Cardiology Associates 400 W. Northwest Hwy Barrington, IL 60010 847.382.4600 Fax 847.382.1771 HIPAA Notice of Privacy Practices ( Notice ) THIS NOTICE DESCRIBES HOW INFORMATION ABOUT YOU MAY

More information

Salt Lake Community College Employee Health Care Benefits Plan Notice of Privacy Practices

Salt Lake Community College Employee Health Care Benefits Plan Notice of Privacy Practices THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. Date: June 1, 2014 Salt Lake Community College

More information

Accredited Home Health Care of America - Notice of Privacy Practices

Accredited Home Health Care of America - Notice of Privacy Practices Accredited Home Health Care of America - Notice of Privacy Practices THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE

More information

COURTNEE A. PELTON, PSY.D.

COURTNEE A. PELTON, PSY.D. 1 COURTNEE A. PELTON, PSY.D. 703-343-0849 CPELTON.PSYCH@GMAIL.COM Outpatient Services Contract Welcome to my practice. This agreement contains important information about my professional services and office

More information

HIPAA NOTICE OF PRIVACY PRACTICES

HIPAA NOTICE OF PRIVACY PRACTICES HIPAA NOTICE OF PRIVACY PRACTICES Marden Rehabilitation Associates, Inc. Marden Rehabilitation Associates of Ohio, Inc. Marden Rehabilitation Associates of West Virginia Health Care Plus Preferred Care

More information

Notice of Privacy Practices

Notice of Privacy Practices Notice of Privacy Practices THIS NOTICE OF PRIVACY PRACTICES DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

More information

NOTICE OF HIPAA PRIVACY AND SECURITY PRACTICES

NOTICE OF HIPAA PRIVACY AND SECURITY PRACTICES SCHOOL DISTRICT OF BLACK RIVER FALLS 523.5 Exhibit NOTICE OF HIPAA PRIVACY AND SECURITY PRACTICES PRIVACY NOTICE This notice describes how medical information about you may be used and disclosed and how

More information

This Notice describes Hill-Rom s practices regarding the use of your Protected Health Information, specifically including:

This Notice describes Hill-Rom s practices regarding the use of your Protected Health Information, specifically including: Original Effective Date: April 1, 2003 Effective Date of Last Revision: July 15, 2013 THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS

More information

HIPAA Notice of Privacy Practices

HIPAA Notice of Privacy Practices HIPAA Notice of Privacy Practices Date of Last Revision: 09/20/2013 Effective Date: Immediately THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS

More information

Privacy Notice Document (HIPAA)

Privacy Notice Document (HIPAA) Privacy Notice Document (HIPAA) THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. This Privacy

More information

Notice of Privacy Practices for Protected Health Information

Notice of Privacy Practices for Protected Health Information Notice of Privacy Practices for Protected Health Information This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review

More information

Notice of Privacy Practices

Notice of Privacy Practices Notice of Privacy Practices THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. Carnegie Mellon

More information

Notice of Privacy Practices

Notice of Privacy Practices Notice of Privacy Practices This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully. This practice uses

More information

River Valley Therapy & Sports Medicine, Inc. Notice of Privacy Practices

River Valley Therapy & Sports Medicine, Inc. Notice of Privacy Practices River Valley Therapy & Sports Medicine, Inc. Notice of Privacy Practices This notice describes how medical information about you may be used and disclosed and how you can get access to this information.

More information

HIPAA HITECH PA Physician Practices

HIPAA HITECH PA Physician Practices NOTICE OF PRIVACY PRACTICES Premier Urology Associates LLC dba Urology Care Alliance SUMMARY Effective Date: 12/20/2012 WHAT IS THIS NOTICE FOR? This Notice of Privacy Practices (Notice) describes how

More information

NOTICE OF PRIVACY PRACTICES

NOTICE OF PRIVACY PRACTICES NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. Important Notice

More information

HIPAA Notice of Privacy Practices Effective Date: 09/23/13

HIPAA Notice of Privacy Practices Effective Date: 09/23/13 HIPAA Notice of Privacy Practices Effective Date: 09/23/13 THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW

More information

Eye Clinic of Bellevue, LTD. P.S. Privacy Policy EYE CLINIC OF BELLEVUE LTD PS NOTICE OF INFORMATION PRACTICES

Eye Clinic of Bellevue, LTD. P.S. Privacy Policy EYE CLINIC OF BELLEVUE LTD PS NOTICE OF INFORMATION PRACTICES Eye Clinic of Bellevue, LTD. P.S. Privacy Policy EYE CLINIC OF BELLEVUE LTD PS NOTICE OF INFORMATION PRACTICES Date of Last Revision: 4/8/03 Effective Date: Immediately This information is made available

More information

OUR LADY OF THE LAKE, HOSPITAL INC. AND OUR LADY OF THE LAKE PHYSICIAN GROUP, LLC NOTICE OF PRIVACY PRACTICES

OUR LADY OF THE LAKE, HOSPITAL INC. AND OUR LADY OF THE LAKE PHYSICIAN GROUP, LLC NOTICE OF PRIVACY PRACTICES OUR LADY OF THE LAKE, HOSPITAL INC. AND OUR LADY OF THE LAKE PHYSICIAN GROUP, LLC NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU

More information

NOTICE OF PRIVACY PRACTICE UCLA COUNSELING AND PSYCHOLOGICAL SERVICES (CAPS)

NOTICE OF PRIVACY PRACTICE UCLA COUNSELING AND PSYCHOLOGICAL SERVICES (CAPS) Effective Date: September 23, 2013 NOTICE OF PRIVACY PRACTICE UCLA COUNSELING AND PSYCHOLOGICAL SERVICES (CAPS) THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW

More information

NOTICE OF PRIVACY PRACTICES Walter Chiropractic Clinic, 5219 Peters Creek Rd Ste 5, Roanoke VA 24019

NOTICE OF PRIVACY PRACTICES Walter Chiropractic Clinic, 5219 Peters Creek Rd Ste 5, Roanoke VA 24019 Effective Date: 5/18/15 NOTICE OF PRIVACY PRACTICES Walter Chiropractic Clinic, 5219 Peters Creek Rd Ste 5, Roanoke VA 24019 THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED

More information

FLORIDA MEDICAL CLINIC, P.A. NOTICE OF PRIVACY PRACTICES

FLORIDA MEDICAL CLINIC, P.A. NOTICE OF PRIVACY PRACTICES FLORIDA MEDICAL CLINIC, P.A. NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW

More information

NOTICE OF TIDEWELL HOSPICE PRIVACY PRACTICES

NOTICE OF TIDEWELL HOSPICE PRIVACY PRACTICES NOTICE OF TIDEWELL HOSPICE PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

More information

Effective April 14, 2003

Effective April 14, 2003 Effective April 14, 2003 THE BOEING COMPANY GROUP HEALTH PLANS NOTICE OF PRIVACY PRACTICES This notice describes how health plan medical information about you may be used and disclosed and how you can

More information

Reason(s) For Referral: Current medications:

Reason(s) For Referral: Current medications: 1540 Sunday Drive Suite 200Raleigh, NC 27607 Office: 919-859-9040FAX: 919-859-9030 Name: Date Examined: Responsible Person: _ Birth Date: Address: Age: Sex: M F Marital Status: S M D W SSN: Home Phone:

More information

HIPAA NOTICE OF PRIVACY PRACTICES UNIVERSITY OF COLORADO HEALTH AND WELFARE PLAN NOTICE OF PRIVACY PRACTICES

HIPAA NOTICE OF PRIVACY PRACTICES UNIVERSITY OF COLORADO HEALTH AND WELFARE PLAN NOTICE OF PRIVACY PRACTICES HIPAA NOTICE OF PRIVACY PRACTICES UNIVERSITY OF COLORADO HEALTH AND WELFARE PLAN NOTICE OF PRIVACY PRACTICES THIS NOTICE OF PRIVACY PRACTICES DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND

More information

NOTICE OF PRIVACY PRACTICES UNIVERSITY OF CALIFORNIA DAVIS HEALTH SYSTEM

NOTICE OF PRIVACY PRACTICES UNIVERSITY OF CALIFORNIA DAVIS HEALTH SYSTEM NOTICE OF PRIVACY PRACTICES Effective Date: April 14, 2003 UNIVERSITY OF CALIFORNIA DAVIS HEALTH SYSTEM THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN

More information

NOTICE OF PRIVACY PRACTICES effective April 14, 2003

NOTICE OF PRIVACY PRACTICES effective April 14, 2003 NOTICE OF PRIVACY PRACTICES effective April 14, 2003 This document outlines the privacy practices of Dental Clinic of Marshfield S.C. and Dental Com Insurance Plan, Inc. All references to Dental Clinic

More information

Notice of Privacy Practices

Notice of Privacy Practices Notice of Privacy Practices Effective September 20, 2013 THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW

More information

The Family Counseling Center of Fulton County NOTICE OF PRIVACY PRACTICES

The Family Counseling Center of Fulton County NOTICE OF PRIVACY PRACTICES The Family Counseling Center of Fulton County NOTICE OF PRIVACY PRACTICES This notice describes the privacy practices of The Family Counseling Center of Fulton County and the privacy rights of the people

More information

Notice of Privacy Practices

Notice of Privacy Practices Notice of Privacy Practices THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. About this notice

More information

Cooper Dental Group Notice of Privacy Practices

Cooper Dental Group Notice of Privacy Practices Cooper Dental Group Notice of Privacy Practices THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

More information

Polk Medical Center Notice of Privacy Practices

Polk Medical Center Notice of Privacy Practices Polk Medical Center Notice of Privacy Practices THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

More information

EXCEL PHYSICAL THERAPY, INC.

EXCEL PHYSICAL THERAPY, INC. EXCEL PHYSICAL THERAPY, INC. Medical History Form Name: Date of Birth: Date: Are you employed? YES NO Right Handed Left Handed If NO, last day worked? Do you smoke? YES NO #of packs/day Occupation: Height:

More information

Wyoming School Boards Association Insurance Trust ( The Plan ) HEALTH CARE PLAN PRIVACY NOTICE

Wyoming School Boards Association Insurance Trust ( The Plan ) HEALTH CARE PLAN PRIVACY NOTICE Wyoming School Boards Association Insurance Trust ( The Plan ) HEALTH CARE PLAN PRIVACY NOTICE THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS

More information

Greater Dallas Orthopaedics, PLLC. Notice of Privacy Practices

Greater Dallas Orthopaedics, PLLC. Notice of Privacy Practices Notice of Privacy Practices This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully. Uses and Disclosures

More information

NOTICE OF PRIVACY PRACTICES Allergy Treatment Center of New Jersey, P.C. Effective Date: April 14, 2003

NOTICE OF PRIVACY PRACTICES Allergy Treatment Center of New Jersey, P.C. Effective Date: April 14, 2003 Allergy Treatment Center of New Jersey, P.C. 388 Pompton Avenue 415 Avenel Street Cedar Grove, NJ 07009 Avenel, NJ 07001 (973) 857 9890 (732) 636-7030 NOTICE OF PRIVACY PRACTICES Allergy Treatment Center

More information

NOTICE OF PSYCHOLOGIST S POLICIES AND PRACTICES TO PROTECT THE PRIVACY OF YOUR HEALTH INFORMATION

NOTICE OF PSYCHOLOGIST S POLICIES AND PRACTICES TO PROTECT THE PRIVACY OF YOUR HEALTH INFORMATION Effective Date: 09/23/2013 Paul Beljan, PsyD, ABPdN, ABN Alison E.F. Reuter, PhD, ABPdN Laura Wingers, PsyD Kate Bree, PsyD Vanessa Berens, PhD Jacob Boney, PsyD, BCBA-D 9835 E. Bell Rd., Ste. 140 Scottsdale,

More information

NOTICE OF PRIVACY PRACTICES

NOTICE OF PRIVACY PRACTICES NOTICE OF PRIVACY PRACTICES This notice describes how your medical information may be used and disclosed, and how you can get access to this information. Chaparral House is required to provide you this

More information

Notice of Privacy Practices

Notice of Privacy Practices Notice of Privacy Practices Pueblo Radiology Medical Group, Inc. Pueblo Radiology Associates, Inc. Central Coast Radiology Associates, Inc. Santa Barbara Women s Imaging Center Effective Date: September

More information

HIPAA Omnibus Notice of Privacy Practices Effective Date: March 03, 2012 Revised on: July 1, 2015

HIPAA Omnibus Notice of Privacy Practices Effective Date: March 03, 2012 Revised on: July 1, 2015 HIPAA Omnibus Notice of Privacy Practices Effective Date: March 03, 2012 Revised on: July 1, 2015 Mobile Physician Group PC 231 High Street Suite 1, Mount Holly, NJ 08060 1-855-MPG-DOCS THIS NOTICE DESCRIBES

More information

SDC-League Health Fund

SDC-League Health Fund SDC-League Health Fund 1501 Broadway, 17 th Floor New York, NY 10036 Tel: 212-869-8129 Fax: 212-302-6195 E-mail: health@sdcweb.org NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION

More information

Bradley D. Powell, PhD NOTICE OF PRIVACY PRACTICES: Effective June 1, 2004

Bradley D. Powell, PhD NOTICE OF PRIVACY PRACTICES: Effective June 1, 2004 Bradley D. Powell, PhD NOTICE OF PRIVACY PRACTICES: Effective June 1, 2004 A Summary of the Provisions of the Health Insurance Portability and Accountability Act ( HIPAA ) Privacy Rule (45 C.F.R. parts

More information

NOTICE OF PRIVACY PRACTICES

NOTICE OF PRIVACY PRACTICES Effective Date: September 23, 2013 THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. OUR PLEDGE

More information

ATLANTIS CHIROPRACTIC, INC.

ATLANTIS CHIROPRACTIC, INC. ATLANTIS CHIROPRACTIC, INC. NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THAT INFORMATION PLEASE REVIEW THIS

More information

Community Health of South Florida, Inc. 10300 SW 216 th Street Miami, FL 33190. Notice of Privacy Practices

Community Health of South Florida, Inc. 10300 SW 216 th Street Miami, FL 33190. Notice of Privacy Practices Community Health of South Florida, Inc. 10300 SW 216 th Street Miami, FL 33190 Effective Date: April 2003 THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN

More information

HIPAA NOTICE TO PATIENTS

HIPAA NOTICE TO PATIENTS HIPAA NOTICE TO PATIENTS THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. Federal regulations

More information

ALABAMA FAMILY EYE CARE, INC.

ALABAMA FAMILY EYE CARE, INC. ALABAMA FAMILY EYE CARE, INC. 5356 Stadium Trace Parkway Suite 100 Hoover, AL 35244 (205) 733-0507 : This notice describes how medical information about you may be used and disclosed and how you can get

More information

NOTICE OF PRIVACY POLICY. Effective:, 2013

NOTICE OF PRIVACY POLICY. Effective:, 2013 THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE READ IT CAREFULLY. NOTICE OF PRIVACY POLICY Effective:, 2013 The

More information

Kiran Mishra, Ph.D. Licensed Clinical Psychologist. Sugar Land, TX 77478 (832) 876-3232 TEXAS NOTICE FORM

Kiran Mishra, Ph.D. Licensed Clinical Psychologist. Sugar Land, TX 77478 (832) 876-3232 TEXAS NOTICE FORM Kiran Mishra, Ph.D. Licensed Clinical Psychologist 1111 Highway 6, Suite 235 Sugar Land, TX 77478 (832) 876-3232 TEXAS NOTICE FORM Notice of Psychologists Policies and Practices to Protect the Privacy

More information

PRIVACY NOTICE. In certain situations, we may also disclose patient information to another provider or health plan for their health care operations.

PRIVACY NOTICE. In certain situations, we may also disclose patient information to another provider or health plan for their health care operations. 1 PRIVACY NOTICE THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. This Privacy Notice is being

More information

Harris County - Texas HIPAA Notice of Privacy Practices

Harris County - Texas HIPAA Notice of Privacy Practices Harris County - Texas HIPAA Notice of Privacy Practices Effective Date: September 23, 2013. THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS

More information

IRVING & ASSOCIATES IN BEHAVIORAL HEALTH, P.C. 5151 Mochel Drive, Suite 307 Downers Grove, IL 60515

IRVING & ASSOCIATES IN BEHAVIORAL HEALTH, P.C. 5151 Mochel Drive, Suite 307 Downers Grove, IL 60515 : / / Client Name: _ SSN: / / of Birth: Age: Sex: Male Female Address: City/State/Zip: Home Phone Number Is it okay to leave a message here? Y/N Work Number Is it okay to leave a message here? Y/N Cell

More information

Office Policies, Informed Consent for Treatment, and Protecting the Privacy of Your Health Record

Office Policies, Informed Consent for Treatment, and Protecting the Privacy of Your Health Record Office Policies, Informed Consent for Treatment, and Protecting the Privacy of Your Health Record Welcome to my office! Below is some information you may wish to read before your first appointment. Included

More information

If you are under 18 years of age, your parents or guardian must sign for you and handle your privacy rights for you.

If you are under 18 years of age, your parents or guardian must sign for you and handle your privacy rights for you. HIPAA NOTICE OF PATIENT PRIVACY PRACTICES CWCC618 Exhibit A Effective Date: November 1, 2011 THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS

More information

The Health and Benefit Trust Fund of the International Union of Operating Engineers Local Union No. 94-94A-94B, AFL-CIO. Notice of Privacy Practices

The Health and Benefit Trust Fund of the International Union of Operating Engineers Local Union No. 94-94A-94B, AFL-CIO. Notice of Privacy Practices The Health and Benefit Trust Fund of the International Union of Operating Section 1: Purpose of This Notice Notice of Privacy Practices Effective as of September 23, 2013 THIS NOTICE DESCRIBES HOW MEDICAL

More information

HIPAA Notice of Privacy Practices - Sample Notice. Disclaimer: Template Notice of Privacy Practices (45 C.F.R. 164.520)

HIPAA Notice of Privacy Practices - Sample Notice. Disclaimer: Template Notice of Privacy Practices (45 C.F.R. 164.520) HIPAA Notice of Privacy Practices - Sample Notice Disclaimer: Template Notice of Privacy Practices (45 C.F.R. 164.520) The information provided in this document does not constitute, and is no substitute

More information

Patti Levin, LICSW, Psy.D. Clinical Psychologist

Patti Levin, LICSW, Psy.D. Clinical Psychologist Patti Levin, LICSW, Psy.D. Clinical Psychologist 673 Boylston St. #4. 617.227.2008 Boston, MA02116 fax: 617.247.7523 www.drpattilevin.com email:patti@drpattilevin.com Notice of Privacy Practices (HIPAA)

More information

Spracklin Chiropractic Andrew Spracklin D.C.

Spracklin Chiropractic Andrew Spracklin D.C. Spracklin Chiropractic Andrew Spracklin D.C. PRIVACY NOTICE VERSION 1.2 THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THAT INFORMATION.

More information

Connecticut Carpenters Health Fund Privacy Notice

Connecticut Carpenters Health Fund Privacy Notice Connecticut Carpenters Health Fund Privacy Notice THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

More information

PLLC NOTICE OF PRIVACY PRACTICES

PLLC NOTICE OF PRIVACY PRACTICES PLLC THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE READ IT CAREFULLY. NOTICE OF PRIVACY PRACTICES The following

More information

Protected Health Information. Notice Information. Notice of Privacy Practices. Nystrom & Associates, Ltd Family Support Services, Inc.

Protected Health Information. Notice Information. Notice of Privacy Practices. Nystrom & Associates, Ltd Family Support Services, Inc. Nystrom & Associates, Ltd Family Support Services, Inc. Notice of Privacy Practices (HIPAA and State Law) And Client Privacy Statement Federal and state privacy and medical records laws protect your rights

More information

PATIENT INTAKE FORM PATIENT INFORMATION. Name Soc. Sec. # Last Name First Name Initial Address. City State Zip. Home Phone Work/Mobile Phone

PATIENT INTAKE FORM PATIENT INFORMATION. Name Soc. Sec. # Last Name First Name Initial Address. City State Zip. Home Phone Work/Mobile Phone PATIENT INTAKE FORM PATIENT INFORMATION Name Soc. Sec. # Last Name First Name Initial Address City State Zip Home Phone Work/Mobile Phone Sex M F Age Birth date Single Married Widowed Separated Divorced

More information

ACKNOWLEDGEMENT OF RECEIPT OF WESTERN DENTAL S NOTICE OF PRIVACY PRACTICE

ACKNOWLEDGEMENT OF RECEIPT OF WESTERN DENTAL S NOTICE OF PRIVACY PRACTICE ACKNOWLEDGEMENT OF RECEIPT OF WESTERN DENTAL S NOTICE OF PRIVACY PRACTICE By signing this document, I acknowledge that I have received a copy of Western Dental s Joint Notice of Privacy Practices. Name

More information

Delaware Valley Dermatology Group, LLC 3411 Silverside Road Suite 107, Webster Building Wilmington, DE 19810 Phone: 302-478-8532 Fax: 302-478-8536

Delaware Valley Dermatology Group, LLC 3411 Silverside Road Suite 107, Webster Building Wilmington, DE 19810 Phone: 302-478-8532 Fax: 302-478-8536 Delaware Valley Dermatology Group, LLC 3411 Silverside Road Suite 107, Webster Building Wilmington, DE 19810 Phone: 302-478-8532 Fax: 302-478-8536 Notice of Privacy Practices THIS NOTICE DESCRIBES HOW

More information