Hipaa Notice Of Privacy Practices Template (Page 3 of 3) in pdf

Hipaa Notice Of Privacy Practices Template Page 3

Complaints

You may complain to us or the Secretary of Health and Human Services if you believe your privacy rights have been

violated by us. You may file a complaint with us by notifying our Compliance Officer of your complaint. We will not

retaliate against you for filing a complaint.

This notice was published and becomes effective on/or before April 14, 2003. Revised October 2013.

___________________________________________________________________________________________

We are required by law to maintain the privacy of, and provide individuals with, this notice of our legal duties and privacy

practices with respect to protected health information. We are also required to abide by the terms of the notice currently in

effect. If you have any objections to this form, please ask to speak with our HIPAA Compliance Officer in person or by

phone at our Main Phone Number. Please sign the accompanying “Acknowledgement” form. Please note that by signing

the Acknowledgement form you are only acknowledging that you have received or been given the opportunity to receive a

copy of our Notice of Privacy Practices.

Signature below is only acknowledgement that you have received this Notice of our Privacy Practices:

Patient

Name:

__________________________________________

Date:______________________________________

Parent/Guardian

Name:

___________________________________

Signature:______________________________________

Hipaa Notice Of Privacy Practices Template Page 3