HIPAA Compliance

Name

I acknowledge that I have access to the Notice of Privacy Practice on the Rock Landing Psychological Group website or on paper if requested, which describes the ways in which the practice may use and disclose my healthcare information for its treatment, payment, healthcare operations and other described and permitted uses and disclosures, I understand that I may contact the Privacy Officer, if I have a question or complaint. I understand that this information may be disclosed electronically by the Rock Landing Psychological Group Provider and/or the Rock Landing Psychological Group Provider’s business associates. To the extent permitted by law, I consent to the use and disclosure of my information for the purposes described in the practice’s Notice of Privacy Practice.

I Acknowlege the Notice of Privacy Practices

I Acknowlege

Disclosures to Friends and/or Family Members

DO YOU WANT TO DESIGNATE A FAMILY MEMBER OR OTHER INDIVIDUAL WITH WHOM THE PROVIDER MAY DISCUSS YOUR MEDICAL CONDITION? IF YES, WHOM?

I give permission for my Protected Health Information to be disclosed for purposes of communicating results, findings and care decisions to the family members and others listed below:

Name and Relationship

In Person

Notify In Person

By Phone

Notify By Phone

Phone Number (If Applicable)

Name and Relationship

In Person

Notify In Person

By Phone

Notify By Phone

Phone Number (If Applicable)

Name and Relationship

In Person

Notify In Person

By Phone

Notify By Phone

Phone Number (If Applicable)

Patient/Representative may revoke or modify this specific authorization and that revocation or modification must be in writing.

Signature

Clear

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Where We Are

Rock Landing Psychological Group, PLC
The James Building
11825 Rock Landing Drive
Newport News, VA 23606
Phone: (757) 873-1736
Fax: (757) 873-1028