ACKNOWLEDGEMENT OF HIPPA PRIVACY NOTICE AND DESIGNATION OF DISCLOSURE

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Acknowledgement of Practice's Notice of HIPPA Privacy:
I have received a copy of the Notice of HIPPA Privacy for The Orthopedic Institute of New Jersey.

Name of Patient :      Signature:      Date:  

Email:  

Designation of Certain Relatives, Close Friends, and Other Caregivers:
I agree that the practice may disclose my health information to a family member, close personal friend or other caregiver, since such person is involved with my health care or payment relating to my health care. In that case, the practice will disclose only information that is directly relevant to the person's involvement with my health care or payment relating to my health care. I wish to be contacted in the following manner (circle all that apply):
Oral Communication:
Home telephone number:  
OK to leave message with detailed information
Leave message with call back number only
Oral Communication:
OK to mail to my home address
OK to mail to my work/office address
OK to email to my email address
Work Telephone Number:  
OK to leave message with detailed information
Leave message with call back number only
Fax Communication:  
OK to fax to this number
I designate the following person listed below as persons involved with my health care or payment relating to my health care for the purpose of the practice making the limited disclosures described above. I understand that I am not required to list anyone. I also understand that I may change this list any time in writing.

Patient Name:    Last four digits of SS Number (required)  
Patient Name:    Last four digits of SS Number (required)  
Patient Name:    Last four digits of SS Number (required)  
Patient Name:    Last four digits of SS Number (required)  

The following person(s) are not authorized to receive my patient health information:
Print Name:    Print Name:  

The Privacy Notice generally requires healthcare providers to take reasonable steps to limit the use or disclosure of, and request for, Patient Health Information to the minimum necessary to accomplish the intended purpose. These provisions do not apply to uses or disclosures made pursuant to an authorization requested by the patient/parent/guardian. Healthcare entities must keep a record of Patient Health Information disclosures. Information provided above will constitute an adequate record. Uses and disclosures for Treatment, Payment, and Healthcare Operations may be permitted without prior consent.

Name of Patient :      Signature:      Date: