Patient Privacy Policy Form


PH: (630) 932-2055 FAX: (630) 932-2059

Acknowledgement of Receipt of Notice of Privacy Practices
Consent to the Use and Disclosure of Medical Information for
Treatment, Payment and Healthcare Operations

  1. We are required by law to maintain the privacy of, and provide individuals with, this notice of our legal duties and privacy practices with respect to protected health information. If you have any questions, please ask to speak to our HIPAA Compliance Officer (Janyce Agruss) in person or by phone at 630-932-2055. Your signature at the bottom of this page is only acknowledgement that you have received this Notice of our Privacy Practices (NOPP).
  2. I consent to the use or disclosure of my medical information by Yorktown Health the purpose of diagnosing or providing treatment to me, obtaining payment for my treatment or to conduct healthcare operations of the practice.
  3. I understand that I have the right to request restrictions, for information not discussed in the NOPP, as to how this information is used or disclosed for treatment, payment or healthcare operations and that Yorktown Health is not required to agree to the restrictions that I may request, but if the practice agrees to a restriction, the practice is bound by the agreement.
  4. I have the right to revoke this consent, in writing, except where the practice has already made disclosures in reliance on prior consent.
  5. Yorktown Health has the right to change the privacy practices that are described in the NOPP. I may obtain a revised NOPP by calling the office and requesting a revised copy be sent in the mail or asking for one when I am in the office.
MM slash DD slash YYYY