Patient HIPPA Acknowledgement Form

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HIPPA Privacy

THIS NOTICE DESCRIBES HOW HEALTHCARE INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Our commitment at Dr. Frank Ruffino's is to serve our patients with professionalism and care, being sure at all times to protect the privacy and security of all Protected Health Information.

During the course of serving your interests it may be necessary to share information with other healthcare providers or business associates. The following are examples of instances where information may be shared:
- During treatment, we may find it necessary to acquire a laboratory analysis.
- For payment purposes, we may use the services of a billing service.
- During healthcare operations, we may need a second opinion.
Dr. Ruffino's staff may leave a message with any adult in my household if necessary.*
- Yes
- No
Dr. Ruffino's staff may leave a voicemail message regarding appointments, treatment or co-pays at my home or cell phone numbers I have provided.*
- Yes
- No
We at Dr. Ruffino's are committed to obeying all Federal, State and local laws and regulations regarding Privacy Practices. If any other uses or disclosures than the ones listed above are needed, the information will only be released with the written authorization of the individual in question. This written authorization may be revoked at any time by the individual, as provided for by law.

If you have any questions or comments regarding your Protected Health Information, feel free to contact our office at 586-799-4240.
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I have read and understand the above Notice of Privacy Practices.
Patient Printed Name*
Signature of Patient/Legal Guardian*
Date*
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Patient HIPPA Acknowledgement Form

HIPPA Privacy

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