Form Cms-R-131 - Application For Peripheral Neuropathy Treatment Page 6
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10We are required by law to maintain the privacy of your health
Patient Name(s):
information and to provide to you and your representative this Notice
of our Privacy Practices. We are required to practice the policies and
_______________________________________________________________
procedures described in this notice but we do reserve the right to
change the terms of our Notice. If we change our privacy practices we
_______________________________________________________________
will be sure all of our patients receive a copy of the revised Notice.
You have the right to express complaints to us or to the Secretary of
Thank you very much for taking time to review how we are carefully
Health and Human Services if you believe your privacy rights have been
using your health information. If you have any questions we want to
compromised. We encourage you to express any concerns you may
hear from you. If not we would appreciate very much your
have regarding the privacy of your information. Please let us know of
acknowledging you r receipt of our policy by signing and returning this
your concerns or complaints in writing.
card. We look forward to seeing you again soon!
Patient Acknowledgment
Patient Signature
Date
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