UROLOGY
85 Prescott Street, Suite 304
Worcester, MA 01605
Tel. (508) 753-7259
Fax: (508) 753-9577
OUR PRIVACY PRACTICES INFORMATION
By signing this form, you acknowledge that this Medical Practice has informed you of its Notice of Privacy Practices policy. This notice is posted in plastic on our waiting room door.
This notice explains how your health information will be handled. A Federal law about medical privacy called HIPAA requires this notice. Please note, our office routinely sends notices to patients regarding lab results, appointments and billing issues. We also make phone calls to the numbers you have given us regarding the same issues.
I HAVE REVIEWED A COPY OF THE NOTICE OF PRIVACY PRACTICES FOR THIS OFFICE AND UNDERSTAND ITS CONTENT. IF I HAVE QUESTIONS ABOUT THIS NOTICE, I UNDERSTAND THAT I MAY CONTACT THE OFFICE WITH THOSE QUESTIONS.
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PATIENT OR GUARDIAN NAME AND SIGNATURE
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BELOW IS FOR OUR OFFICE USE ONLY:
If patient did not sign explain why below:
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STAFF NAME AND SIGNATURE
DATE