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HIPAA PRIVACY NOTICE

I. Acknowledgement of Practice's Notice of HIPAA Privacy

___________________________________________ __________________

Name of Patient Date of Birth

___________________________________________ __________________

Signature of Patient/Parent/Guardian Date

II. Designation of Certain Relatives, Close Friends, Care Givers

A. I agree that the practice may disclose certain of my health information to a family member, close personal friend, or other caregiver, since such a person is involved with my health care or payment relating to my health care. In that case, the Physical 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. I wish to be contacted in the following manner(s):

Home Phone: _____________________________

Check: o Ok to leave message with detailed information

o Leave call back numbers only

Work Phone: _____________________________

Check: o Ok to leave message with detailed information

o Leave call back numbers only

Cell Phone: _____________________________

Check: o Ok to leave message with detailed information

o Leave call back numbers only

Written Communication:

Check: o Ok to mail my home address

o Not ok to mail my home address

B. I designate the following persons listed below as persons involved with my health care or payment relating to my health care for the purpose of the practice making the limited disclosures described above. I understand that I am not required to list anyone. I also understand that I may change this list at any time in writing.

Print Name: ____________________________________________________________

Print Name: ____________________________________________________________

Print Name: ____________________________________________________________

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THIS ---->https://backandnecksupport.com/hippa-privacy-notice.html

Office Hours

DayMorningEvening
Monday8:45-12:003:00-7:00
Tuesday8:45-12:00
Wednesday8:45-12:003:00-7:00
ThursdayAppointmentOnly
Friday8:45-12:003:00-6:15
Saturday8:30-11:30
Sunday
Day Morning Evening
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
8:45-12:00 8:45-12:00 8:45-12:00 Appointment 8:45-12:00 8:30-11:30
3:00-7:00 3:00-7:00 Only 3:00-6:15

Testimonial

We value our patients' experience at Forzani Family Chiropractic Center. If you are currently a patient, please feel free to complete the following Client Experience Questionnaire. The Questionnaire is in Adobe Acrobat format, and requires the free Acrobat Reader to view.

Download & Print Questionnaire

Dr. Lisa Forzani
Wall Chiropractor | Forzani Family Chiropractic Center |  (732) 974-9100

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