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Patient HIPAA Acknowledgement & Designation Disclosure Form

Acknowledgment of Practice’s Notice of Privacy Practices: 

By subscribing my name below, I acknowledge that Neurovations Clinic has provided a copy of the Notice of Privacy Practices (NPP) and that I have read (or had the opportunity to read if I so chose) and understand my rights and ask questions regarding my rights and receive answers to my satisfaction and agree to its terms.

Designation of Certain Relatives, Close Friends, and other Caregivers as my Personal Representative

I agree that the practice may disclose certain of my health information to a Personal Representative of my choosing, since such person is involved with my health care or payment relating to my health care. In this case, the Physician Practice will disclose only information that is directly relevant to the person’s involvement with my health care or payment relating to my health care.


acting on behalf of my minor son/daughter

As legal Personal Representative in all matters. If the representative is a court-appointed legal guardian, a copy of court documents must be provided and kept in medical records.

Request to Receive Confidential Communications by Alternative Means

I understand that as part of my health care and treatment, Neurovations Clinic may need to reach me by phone. As provided by Privacy Rule Section 164.522(b), 

Preference for leaving messages

Thanks for submitting!

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