Privacy Policy
NOTICE OF PRIVACY PRACTICES ACKNOWLEDGMENT
Montclair Vision Services
Dr. Ted Friedman O.D.
103 Park Street
Montclair, NJ 07042
I understand that under the Health Insurance Portability & Accountability Act of 1996 ("HIPAA"), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used:
- <!--[if !supportLists]--> Conduct, plan, and direct any treatment and follow-up among the multiple health care providers who may be involved in that treatment directly and indirectly.
- <!--[if !supportLists]-->Obtain payment from third-party payers.
- <!--[if !supportLists]-->Conduct normal health care operations such as quality assessments and physician certifications.
I have received, read, and understand your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I understand that this organization has the right to change the Notice of Privacy Practices from time and that I may contact this organization at any time at the above address to obtain a current copy of the Notice of Private Practices.
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 restrictions, but if you do agree then you are bound to abide by such restrictions.