Please click here to download the Privacy Practice Form: Privacy Practice Forms
This is a copy of what you will be downloading:
ACKNOWLEDGEMENT OF PRIVACY PRACTICE NOTICE
AND DESIGNATION OF DISCLOSURE
I. Acknowledgement of Privacy Practice Notice
I have received a copy of the Heart Specialists Group’s Notice of Privacy Practices.
I hereby consent to the use or disclosure of my protected health information by, or on behalf of,
The Heart Specialists Group, LLC for purposes of treatment, payment or healthcare operations.
I understand that my protected health information may be used for such purposes without my written authorization.
____________________________ _________________
Print Patient’s Name Date of Birth
______________________________________ _________________
Signature of Patient/Parent/Guardian Date
- Check here if you do not wish voice messages to be left on your answering
machine or voicemail.
Daytime phone number:______________________
II. Designation of Certain Relatives, Close Friends and Other Caregivers
I agree that The Heart Specialists Group, LLC may disclose certain documents
regarding my health information to a family member, close personal friend or other caregiver
because such a person is involved with my health care.
I designate the person(s) listed below as individual(s) involved with my health care provided by
The Heart Specialists Group for the purpose of making the disclosures described above. I understand that I am not
required to list anyone. I also understand that I may change this list at any time by submitting a
written request to The Heart Specialists Group.
Print Name:___________________ Relationship:_______________Date of Birth:_______
Print Name:___________________ Relationship:_______________Date of Birth:_______
Print Name:___________________ Relationship:_______________Date of Birth:_______
_________________________________ ________________
Signature of Patient/Parent/Guardian Date