Privacy Practice Form

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

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:_______

_________________________________ ________________

Signature of Patient/Parent/Guardian Date