HIPPA Disclosure Form

Dear Patients,

We consider the privacy of your health information to be one of the most important elements in our relationship with you. Our responsibility to maintain the confidentiality of your health information is one that we take very seriously. We have taken the following steps to protect your privacy.

Federal legislation concerning patient privacy requires health care providers, health insurance companies and other health-related organizations to bolster their privacy practices as of April 14, 2003.

Attached with this letter is our Acknowledge Form and the Notice of Health Information Privacy Practices. We are pleased to provide this information to our patients and to comply with the privacy regulations of the federal Health Insurance Portability and Accountability Act (HIPPA).

To help us comply with the new law, we ask that you do the following:

1. Read the Notice of Privacy Practices and Office Policies on the pages that follow.

2. Complete the Acknowledgement Form Below

Orna Goldwater, PhD Licensed Psychologist & HSP

NPI: 1770595852

Acknowledgment

I hereby acknowledge that I received a copy of this medical practice’s Notice of Privacy Practices. I further acknowledge that a copy of the current notice will be posted in the reception area, and that I will be offered a copy of any amended Notice of privacy practices upon request.