Dermatology of Seattle

13610 First Avenue South, Seattle, WA 98168

206-248-5020 – 206-244-8425 (fax)

 

NOTICE OF PRIVACY PRACTICES – ACKNOWLEDGEMENT

 

We are concerned with your privacy rights. We are complying with national guidelines (HIPPA) to safeguard your personal health information.

 

We keep a record of the healthcare services we provide you. You may ask to see and copy that record. You may also ask to correct that record. We will not disclose your record to others unless you direct us to do so or unless the law authorized or compels us to do so. You may see your record or get more information about it by contacting our privacy officer or any front office staff member.

 

Our Notice of Privacy Practices describes in more detail how your health information may be used and disclosed, and how you can access your information.

 

***Please take the time to read the entire document. ***

 

We routinely call your home phone or other phone number(s) you have listed in your chart to remind you of appointment, discuss treatments, or give test results. You must let us know, in writing, if you have other preferences for contacting you.

 

_____ Home Phone:   (_______)_______-__________

_____ Cell Phone:       (_______)_______-__________

_____ Work Phone:    (_______)_______-__________

_____ E-Mail:             __________________________ (You may communicate personal, private & confidential information regarding my treatment to this secure email address.)

_____ Mail

_____ You may leave messages with these people: ______________________________

__________________________________________________________________

_____ Any other specific requests about how we may contact you: _________________

            __________________________________________________________________

 

(Notation, if any, by staff)

 

By my signature below, I acknowledge receipt of the Notice of Privacy Practices.

 

 

________________________________                    ______________________________

Patient or legally authorized individual                                                                    Date                                                                Time

 

 

_______________________________                      ______________________________

Printed name if signed on behalf of the patient                                      Relationship

                                                                                    (parent, legal guardian, personal representative)

 

This form will be retained in your medical record.