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Patient Acknowledgement
Grace Medical Clinic is required by law to maintain the privacy of protected information. This practice is required to abide by the terms of the notice currently in effect.
Types of uses and disclosures that this practice is permitted to make are:
Treatment, payment, and health care operations.
A description of each of the other purposes for which this practice is permitted or required to use or disclose protected health information without my consent or authorization.
A description of use and disclosures that are prohibited or materially limited by law.
A description of other uses and disclosures that will be made only with my written authorization and that I may revoke such authorization.
My individual rights with respect to protected and a brief description of how I may exercise these rights in relation to:
The right to complain to this practice and to the Secretary of HHS if I believe that my privacy rights have been violated, and that no retaliatory actions will be used against me in the event of such a complaint.
The right to request restrictions on certain uses and disclosures of my protected health information, and that this practice is not required to agree to a requested restriction.
The right to receive confidential communication of protected information.
The right to inspect and copy protected health information.
The right to amend protected health information.
The right to receive an accounting of disclosures of protected health information.
The right to obtain a paper copy of the Notice of Privacy Practices from Grace Medical Clinic upon request.
Grace Medical Clinic reserves the right to change the terms of its Notice of Privacy Practices and to make new provisions effective for all protected health information that it maintains, and I can obtain a copy on request. Additional details are available at www.hhs.gov/ocr/hipaa.
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