Acknowledgement of Receipt of Notice of Privacy Practices
I have received and read the HIPPA Privacy of Practices Notice regarding the uses and disclosures of my Protected Health Information, and I understand my rights and obligations with respect to my medical records.I further acknowledge that a copy of the current notice is available for review at any time. If requested, a paper and/or electronic copy of the HIPPA Privacy Practices will be provided to me by Four Peaks Neurology. I understand that any amended Notice of Privacy Practices will be made available to me.
I hereby authorize Four Peaks Neurology to release any medical or incidental information to my referring physician or any other physicians who have been or may become involved with my care.
I also authorize the release of information that may be necessary in the processing of any insurance claims.
I also authorize the release of any medical records, including pharmacy records, to Four Peaks Neurology upon request.
Faxes: When expedient, I authorize the transmittal of my records by FAX to doctors, pharmacies, insurance companies, or upon my request. I understand that transmission by FAX, by its very nature, is not confidential.
Four Peaks Neurology, P.C.
