HIPAA Privacy Acknowledgment

Please read and acknowledge our Notice of Privacy Practices before your first appointment. All information is kept strictly confidential.

Patient Information

First Name*

Last Name*

Date of Birth

Phone*

Email Address*

Relationship to Patient

Street Address

City

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Notice of Privacy Practices

Notice of Privacy Practices — Summary

Breakthrough Healthcare Solutions is committed to protecting your health information. This notice describes how medical information about you may be used and disclosed and how you can get access to this information.

We may use and share your health information to provide treatment, obtain payment for services, and conduct normal healthcare operations. We may also share information as required by law, for public health activities, or in emergency situations.

You have the right to request restrictions on how we use or disclose your health information, to receive confidential communications, to inspect and copy your health information, to request amendments, and to receive an accounting of disclosures.

To exercise any of these rights or to obtain a full copy of our Notice of Privacy Practices, please contact our office at (904) 260-1993 or jennifer@breakthroughhc.com.

Acknowledgment & Signature

Acknowledgment Statements

I have received and/or had the opportunity to review the Notice of Privacy Practices of Breakthrough Healthcare Solutions.

I understand that Breakthrough Healthcare Solutions may use and disclose my protected health information for treatment, payment, and healthcare operations as described in the Notice of Privacy Practices.

I understand I have the right to request restrictions on how my health information is used or disclosed, though the practice is not required to agree to those restrictions.

I understand I may revoke this acknowledgment in writing at any time, except where the practice has already taken action in reliance on it.

Signature (Type Full Name)*

Date Signed*

By typing your full name above, you are providing your electronic signature and acknowledging the statements above.

Fields marked * are required. This form is submitted securely and kept strictly confidential.