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Privacy Policy



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 to:

  • Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment,
  • Obtain payment from third-party payers,
  • Conduct normal healthcare operations such as quality assessment and physician certifications.

I have received, a copy of 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 its Notice of Privacy Practices from time to time and that I may contact this organization at any time at the address below to obtain a current copy of the Notice of Privacy 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 other health care operations. I also understand you are not required to agree to my requested restrictions, but if you do agree you are bound to abide by such restrictions.

Release of Information

Please list below the person or persons with whom we may discuss your care. You may revoke this authorization at any time.

Name: ___________________________________       Relationship: _____________

Name: ___________________________________       Relationship: _____________

Name: ___________________________________       Relationship: _____________

Name: ___________________________________       Relationship: _____________

Name: ___________________________________       Relationship: _____________

Name: ___________________________________       Relationship: _____________

Patient Name: ______________________________       Relationship to Patient: _________

Signature: _________________________________       Date: _______________


I attempted to obtain the patient’s signature in acknowledgement on this Notice of Private Practice Acknowledgement, but was unable to do so as documented below:

Date: ________  Name/Signature:  ______________________ Reason:  ___________________________    

2236 W Bethany Home Road, #2, Phoenix, Arizona 85015 . Telephone (602)242-4592 . Fax (602)242-9220 6003 W Thunderbird Road, Suite #1, Glendale / 4921 E Bell Rd #202 , Scottsdale / 10320 W. McDowell Rd, Suite #L1238, Avondale / 3624 W Anthem Way #C-100, Anthem