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NOTICE OF PRIVACY PRACTICES
This notice describes how medical/protected health information about you may be
used and disclosed and how you can get access to this information. Please review
it carefully.
Summary: By law, we are required to provide you with our Notice of Privacy Practices
(NPP). This Notice describes how your medical information may be used and disclosed
by us. It also tells you how can obtain access to this information.
As a patient, you have following rights:
1. The right to inspect and copy your information;
2. The right to request corrections to your information;
3. The right to request that your information be restricted;
4. The right to request confidential communications;
5. The right to a report of disclosures of your information; and
6. The right to a paper copy of this Notice.
We want to assure you that your medical/protected health information is secure with
us. This Notice contains information about how we will insure that your information
remains private.
If you have any questions about this Notice, the name and phone number of our
contact person is listed on this page.
Effective Date of this Notice
Contact Person
Nirmala Polisetty
Phone Number
713-936-2966
Acknowledgement of Notice of Privacy Practices
“I here acknowledge that I have received a copy of this practice’s NOTICE OF PRIVACY
PRACTICES.
I understand that if I have questions or complaints regarding my privacy rights that I may
contact the person listed above. I further understand that the practice will offer me
updates to this NOTICE OF PRIVACY PRACTICES should it be amended, modified or
changed in any way.”
_______________________________________________
Patient or Representative Name (Please Print)
_______________________________________________ ___________________
Patient or Representative Signature
Date
Patient refused to sign
Patient was unable to sign because
____________________
Greater Houston Diabetes & Endocrinology Center (GHDE)

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