AckKnowledgeNoticeOfReceipt

Acknowledgement of Receipt of NOTICE ... Page 1 of 2 Edited by Foxit Reader Copyright(C) by Foxit Software Company,2005-2007 For Evaluation Only. Acknowledgement of Receipt of NOTICE OF PRIVACY PRACTICES at Dr. Alfonso Jimenez Offices and Methods of Communication Between YOU (patient) and Dr. Alfonso Jimenez In general, the HIPAA privacy rule gives individuals the right to request on uses and disclosures of their protected health information (PHI). The individual is also provided the right to request confidential communications or that a communication of PHI be made by alternative means, such as sending correspondence to the individuals office instead of the individuals home. The Privacy Rule generally requires health care providers to to take reasonable steps to limit the use or disclosure of, and requests for PHI to the minimum necessary to accomplish the intended purpose. These provisions do not apply to uses or disclosures made pursuant to an authorization requested by the individual in person. I hereby acknowledge that I have read the Notice of Privacy Practices ( 'Notice') that was given to me upon arrival at Dr. Alfonso Jimenez office. For matters such as appointment reminders, pick up ID cards, and other PHI, I wish to be contacted in the following ways. (check all that apply) HOME TELEPHONE X X ___Leave message to call back Dr. Alfonso Jimenez office ___Okay to leave message with more detailed information. If Yes: (619)231-0734 Phone number:___________________________________ WORK TELEPHONE ___Leave message to call back Dr. Alfonso Jimenez office ___Okay to leave message with more detailed information. If Yes: N/A Phone number:___________________________________ MAIL X ___Okay to mail to my home address ___Okay to mail to my work address If Yes: 340 Kalmia St. San Diego, CA 92101 Address:________________________________________ ________________________________________ ________________________________________ EMAIL: ___Okay to email to my home email ___Okay to email to my work email X If Yes: garyjean@gmail.com Email:__________________________________________ FAX ___Okay to Fax to my home ___Okay to Fax to my wok N/A If Yes: N/A Fax number:_____________________________________ Other People that is Okay to give details to.....for example husband, wife, son, mother....etc. Name/Phone Jean Fletcher (619) 231-0734 number/Relationship:__________________________________________________ (Print Name) (Signature) ___________ ___________________________________ ___________________________________ (date) Note: if patient is a minor, parents/legal guardian must read and sign above http://docs.google.com/View?docID=d2b9ct7_89h97pbhhg&revision=_latest 1/17/2008 Acknowledgement of Receipt of NOTICE ... Page 2 of 2 http://docs.google.com/View?docID=d2b9ct7_89h97pbhhg&revision=_latest 1/17/2008