FHCCGLA Form -

Notice of Privacy Practices

A Notice of Privacy Practices (NPP) is provided to all patients. This Notice of Practices identifies: 1) how medical information about you may used or disclosed; 2) your rights to access your medical information, amend your medical information, request an accounting of disclosures of your medical information, and request additional restrictions on our uses and disclosures of that information; 3) your rights to complain if you believe your privacy rights have been violated; and 4) our responsibilities for maintaining the privacy of your medical information.

The undersigned certifies that she/he has read the foregoing, received a copy of the Notice of Privacy Practices, and is the patient, or the patient’s personal representative.

Patient’s Name: [esiggravity formid=”11″ field_id=”1″ display=”value” ]

[esiggravity formid=”11″ field_id=”8″ display=”label_value” ]

Name of Patient’s Personal Representative (If applicable): [esiggravity formid=”11″ field_id=”6″ display=”value” ]

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FHCCGLA https://fhccgla.com

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April 28, 2020 12:19 pm PDT

Notice of Privacy Practices Uploaded by Admin Name - fdiaz510@gmail.com IP 103.251.19.219