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Savannah Neurology Specialists, PC

  • (912)

    354-7676 Phone

  • (912)

    354-7181 Fax

ACKNOWLEDGEMENT OF THE PRIVACY ACT OF 2007 PATIENT RECORD OF DISCLOSURE

In general the HIPPA privacy rules give individuals the right to request a restriction on uses and disclosures of protected health information (PHI). The individual is also provided the right to request confidential communications of PHI be made by alternative means, such as sending correspondence to the individual’s office instead of their home via mail or fax.

You may also acknowledge that we may leave a message with, discuss you treatment, appointments or other scheduling that may occur or provide other information as necessary with the following family, friends or personal representatives. I understand that Savannah Neurology Specialists will refuse to discuss my information with anyone not listed below, except in an emergency. I also understand that this consent does not apply to medical providers in the treatment of my care.

PLEASE PRINT

1.

3.

___________________________________________

__________________________________________

2.

4.

___________________________________________

__________________________________________

I have received a copy of the Savannah Neurology Specialists “Notice of Privacy Practices” which details how my personal health information may be used and disclosed as permitted under Federal and State law. I have read and understand the contents of the notice.

_______________________________________________ Print Patient’s Name

______________________________________ Date

_______________________________________________ Signature

If not signed by the patient, please indicate the relationship of the person signing to the patient.

_______________________________________________

______________________________________

Name & Relationship

Witness

If a patient/representative refuses to sign this acknowledgement of Receipt, please document why including the date and time.

____________________________________________________________________________________________

Presented and Refused Reason

Name/Title/Date/Time

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