Patient Information Form Page 2

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ANDREW M. BLUMBERG, M.D.
16100 SAND CANYON AVE. #350
IRVINE, CA 92618
(949) 450-0077
We understand that medical information about you and your health is personal. As the custodians of the
information in your medical record, we are committed to protecting the privacy of your information as
required by law, professional accreditation standards and our internal policies and procedures.
Attached is your personal copy of our Notice of Privacy Practices. This notice explains your rights, our
legal duties and our privacy practices. It also describes how medical information about you may be used
and disclosed and how you can get access to this
information.
Please review it carefully.
For your convenience the following is a summary of the information discussed in the notice.
•
Our Pledge
•
Your Personal Information
•
Our Privacy Practices
•
How We May Use or Share Your Information for:
o Treatment
o Payment
o Health Care Operations
o Notifications
o Marketing
o Research
o
Special Circumstances and the Law
•
Your Written Permission
•
Other Restrictions
•
Your Rights
•
Changes
•
Questions or Complaints
Please understand that this summary is not our Notice of Privacy Practices, nor is it a substitute for the
notice. The actual notice should have been given to you, as required by law, with this cover letter. Ifit
was not, please contact our office manager at the address or phone number shown at the top of this page
to receive your copy.
We ask that you sign and return this cover letter to us for our records. Your signature only acknowledges
that we have provided you a personal, paper copy of our Notice of Privacy Practices as required by
law.
The law also requires us to document the fact that we have distributed the notice by collecting and
retaining these signed acknowledgements.
If, after reviewing the notice, you decide that you do not want to retain your paper copy, please return it to
our receptionist and we will recycle it.
I hereby acknowledge receipt of the Notice of Privacy Practices:
Signature
Printed N arne
Date
Child's Name
Relationship

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