1800 Town Center Drive, Suite 411
Reston Virginia 20190
703-437-3236
ACKNOWLEDGEMENT AND CONSENT FOR NOTICE OF PRIVACY PRACTICES
I understand that, under the Health Insurance Portability
& Accountability Act of 1996 (“HIPAA”), I have certain
rights to privacy regarding my protected health information. I understand
that this information can and will be used to:
• Conduct, plan and direct my treatment and follow-up among
the multiple healthcare providers who may
be involved in that treatment directly and indirectly.
• Obtain payment from third-party payers.
• Conduct normal healthcare operations such as quality assessments and certifications.
I acknowledge that I have received your Notice of Privacy
Practices containing a more complete description of
the uses and disclosures of my health information. I understand that Reston
Psychological Center has the right
to change its Notice of Privacy Practices from time to time and that I may
contact Reston Psychological Center
at the address above to obtain a current copy of the Notice of Privacy Practices.
I understand that I may request in writing that Reston Psychological
restrict how my private information is used
or disclosed to carry out treatment, payment or health care operations. I
also understand Reston Psychological
Center is not required to agree to my requested restrictions, but if Reston
Psychological Center does agree, it is
bound to abide by my restrictions.
I may revoke this consent in writing at any time, except to
the extent that Reston Psychological Center has
already taken action relying on this consent.
Patient Name: _______________________________________
(Please Print)
Signature: __________________________________________
Relationship to Patient: ________________________________
Date: ______________________ Therapist:____________________________________