HIPAA Privacy Notice Acknowledgment — Primary Health Clinics of Mississippi

Your Rights Under HIPAA — Summary

Primary Health Clinics of Mississippi is required by law to maintain the privacy of your protected health information (PHI) and to provide you with a Notice of Privacy Practices. Our full Notice of Privacy Practices is available at the front desk and at primaryhealthclinicsofms.com/notice-of-privacy-practices.

As our patient, you have the right to:

Inspect and obtain a copy of your health information
Request corrections to your health information
Request restrictions on how we use or disclose your information
Request confidential communications
Receive an accounting of disclosures of your health information
Receive a paper copy of our Notice of Privacy Practices upon request
File a complaint with us or with the U.S. Department of Health & Human Services if you believe your privacy rights have been violated

We may use and disclose your health information for treatment, payment, and healthcare operations without your separate authorization. Other uses and disclosures require your written authorization, which you may revoke at any time.

Acknowledgment of Receipt

By signing below, I acknowledge that I have been offered a copy of Primary Health Clinics of Mississippi's Notice of Privacy Practices and that I understand my rights as described above. I understand that PHCM may use and disclose my protected health information for treatment, payment, and healthcare operations as described in the Notice.

Patient Signature (or Legal Representative)

Date

Printed Name of Legal Representative (if signing on behalf of patient)

Relationship to Patient

If we are unable to obtain your written acknowledgment, we will document our good-faith effort to do so as required by 45 CFR § 164.520(c)(2)(ii).

Preferred Communication Method

Please indicate how you prefer to receive appointment reminders, test results, and other communications:

Phone call

Text message

Patient portal

Mail

Best phone number for communications

Best email address for communications (if applicable)

Persons authorized to receive information about my care (name and relationship)