Acknowledgement of Receipt of Privacy Notice

In accordance with the privacy standards issued by the United States Department of Health and Human Services, pursuant to the Health Insurance Portability and Accountability Act of 1996 (HIPAA), I hereby consent to CHARLES RIVER MEDICAL ASSOCIATES using and disclosing my protected health care information for the purposes of treatment, billing, and health care operations.

Federal law requires that all patients be given a copy of the CHARLES RIVER MEDICAL ASSOCIATES Privacy Notice. The Privacy Notice describes in detail how patient health information is used and shared with others.

CHARLES RIVER MEDICAL ASSOCIATES has reserved the right to change the Privacy Notice at any time. You may obtain a current copy of the Privacy Notice by contacting the office.

All reasonable efforts will be made to protect the privacy of patient health information, whether it is maintained on paper or electronically, and regardless of how it is communicated, for example, by e-mail or facsimile mail.

You must acknowledge before submitting.
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When the patient is a minor, or is unable to give consent, the signature of a parent, guardian, or other representative is required.