SoFHA
Patient Forms

Notice of Privacy Practices


Description:

The Pinnacle Family Medicine notice of privacy practices.


Code:

1.002

Issued:

04/10/2018

Revision:

1

Revised:

N/A

You can view and/or download related documentation below:

Notice of Privacy Practices

Patient's Rights and Responsibilities

Patient Advisories and Policies





I have been given the opportunity to review the Notice of Privacy Practices and understand that the Notice describes how my protected medical information may be used and disclosed and how I may get access to this information. I have also been given the opportunity to take a copy of the Notice of Privacy Practices for further review.

If for some reason the facility needs to relay my protected medical information, i.e. lab results or billing issues, you can either leave a message on my voice mail/answering machine or discuss the information with the following individual(s):







By typing my name below, I agree to the fore mentioned statements.

I also acknowledge that I have been given a copy of the Patient Advisories and Policies in addition to the Patient's Rights and Responsibilities.

I further acknowledge that I will be seeing my selected physician as my Primary Care Physician.