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).
The health center staff has my permission to leave personal health information as a message on my answering machine.
The health center staff has my permission to share my personal health information with the following person(s):Name Relationship Phone
Name Relationship Phone
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
If you have questions about the contents of this document, you can email the document owner.
Document Name: Acknowledgement of Notice of Privacy Practice
Agree & Sign