Notice of Privacy Practices Acknowledgement

I UNDERSTAND THAT, Under the Health Insurance Portability & Accountability Act of 1998 (HIPAA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:

- Conduct and direct my treatment and follow up among the multiple healthcare providers who may be involved in that treatment directly and indirectly.

- Obtain payment from third-party payers.

- Conduct normal healthcare operations such as quality assessments and physician certifications.

I acknowledge that I have read and understand your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my heath information. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time at the address above to obtain a current copy of the Notice of Privacy Practices.

I acknowledge that I will be receiving automated SMS text message/email reminders about my upcoming appointments, promotions, and new services from Regenerate Men’s Health Medical Clinic and/or its sister clinics. If you would rather opt-out, please notify us.

I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or health care operations. I also understand you are not required to agree to my requested restriction, but if you do agree then you are bound to abide by such restrictions.

Patient Name:

Date:

Office Use Only

I attempted to obtain the patients signature in acknowledgement on the Notice of Privacy Practices Acknowledgment, but was unable to do so as documented below:

Date:

Initials:

Reason: