Notice of Health Information Practices Acknowledgement Form
Dr. Farrah Ortho
The attached notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please sign this cover sheet acknowledging receipt of the policy and return it to the receptionist. Review the policy carefully and lets us know if you have any questions or request.
By my signature below, I acknowledge that I have received the Notice of Health Information Practices of Dr. Farrah Ortho. I understand that the organization reserves the rights to change their notice and practices and prior to implementation will mail a copy of any revised notice to the address I have provided. I understand that I have the right to request restrictions as to how my health information may be used or disclosed and that the organization is not required to agree to the restrictions requested. I understand that I may revoke this content in writing, except to the extent that the organization has already taken action in reliance thereon.