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Acknowledgement of Notice of Privacy Practice

Manet Community Health Center, Inc. | * 6587534w4368 A-HIPAA

Manet Community Health Center will use and disclose your personal health information to treat you, to receive payment for the care we provide, and for other health care operations. We have prepared a detailed NOTICE OF PRIVACY PRACTICES to help you better understand our policies in regard to your personal health information. You have the right to review this notice prior to signing this acknowledgement. The terms of this notice may change with time and we will always post the current notice at our facilities and have copies for distribution. You may ask us to restrict the use and disclosure of your personal health information. However, we are not required to agree to such a request, but if we do agree, we are bound by law to the agreed upon restrictions.

There are times when our patients request that their health care provider include a friend or member of their family in their health care decisions. Please list any family member or friend to whom we may speak or share your personal health information (PHI).

Do not share my personal health information with anyone but me.

The health center staff has my permission to leave personal health information as a message on my answering machine.

Yes

Initials:

The health center staff has my permission to share my personal health information with the following person(s):

Name Relationship Phone

Name Relationship Phone

I acknowledge that I have been given the opportunity to receive, review and ask questions regarding Manet Community Health Center's Notice of Privacy Practice.

Patient Date of Birth:

Name of patient or legal representative:

Relationship to Patient

Please provide email address for Patient Portal:

For internal use only:

MCHC has made a good faith effort to obtain the patient's acknowledgement, but the patient's signature was not obtained for the following reason(s): __________________________________________________________________________________________

Staff Signature: _____________________________________________

Leave this empty:

Your legal name

Your email address

Please Confirm full name and signature.

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Manet Community Health Center https://www.manetchc.org

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June 17, 2020 12:56 pm EST

Acknowledgement of Notice of Privacy Practice Uploaded by Stefanie Curry - stefaniecurry@comcast.net IP 73.227.241.65

June 17, 2020 1:50 pm EST

Manet Registration - registration@manetchc.org added by Stefanie Curry - stefaniecurry@comcast.net as a CC'd Recipient Ip: 73.227.241.65

June 17, 2020 1:50 pm EST

Sandra McGunigle - smcgunigle@manetchc.org added by Stefanie Curry - stefaniecurry@comcast.net as a CC'd Recipient Ip: 73.227.241.65

June 17, 2020 1:54 pm EST

Sandra McGunigle - smcgunigle@manetchc.org added by Stefanie Curry - stefaniecurry@comcast.net as a CC'd Recipient Ip: 73.227.241.65

June 17, 2020 2:39 pm EST

Sandra McGunigle - smcgunigle@manetchc.org added by Stefanie Curry - stefaniecurry@comcast.net as a CC'd Recipient Ip: 73.227.241.65