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HIPPA Patient Form

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Notice of Privacy Practices Acknowledgement

  • I understand that, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:
    • • Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly.
    • • Obtain payment from third-party payers
    • • Conduct normal healthcare operations such as quality assessments and physician certifications
    I acknowledge that I have received your Notice of Privacy Practices containing a more complete description of these uses and disclosures of my health information. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time at the address above to obtain a current copy of the Notice of Privacy Practices.
    I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or health care operations. I also understand that you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions.
  • Click here for the NOTICE OF PRIVACY PRACTICES
 

Verification

 

“Individual results may vary.  Results are not guaranteed with this or any other procedure. Any weight loss procedure should be accompanied with nutritional counselling and an appropriate diet and exercise program.”