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Notice of Privacy Practices

HIPPA Compliance Requirement Patient Consent to the Use / Disclosure of Patient History Information for Treatment,

Payment or Healthcare Operations


I, ___________________________________________, understand that as part of my health care, Anna Dolopo, DACM, Dipl. OM, L.Ac., originates and maintains paper and/or electronic records describing my health history, symptoms, examination and test results, diagnoses, treatment and any plans for future care or treatment. I understand that this information serves as:

A basis for planning my care and treatment,

A means of communication among the health professionals who contribute to my care,

A source of information for applying my diagnosis and treatment to my bill,

A means by which a third party payer can verify services billed were actually provided,

A tool for routine healthcare operations such as assessing quality and reviewing the competence of healthcare professionals.

I understand that as part of this organization’s treatment, payment or healthcare operations, it may become necessary to disclose my protected health information to another entity and I consent to such disclosure for these permitted uses, including disclosures via fax.

A copy of the Notice of Information Practices is available upon request. ___________________________________________ Patient’s Signature


On occasion, Anna Dolopo, DACM, Dipl. OM, L.Ac., may have confidential health information about you, which we may wish to convey to you by telephone.

Please indicate how you want us to handle this:

Write only ___

Do not call ___

Call this number: ________________

My confidential information may be discussed with the following people: _____________________________________________________________________________


Detailed confidential messages may ___ or may not ___ be left at my answering.

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