Notice of Privacy Practices Acknowledgement
Mission Viejo Radiation Oncology Center 27800 Medical Center Road, Suite 160 Mission Viejo, CA 92691

All patients seen are asked to sign this Notice. Please bring this form to your initial consultation appointment.

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 health care providers who may be involved in that treatment directly and indirectly.
• Obtain payments from third-party payers.
• Conduct normal health care operations such as quality assessments and physician certification.

I have received, read, and understand your “Notice of Privacy Practices” containing a more complete description of the uses and disclosure of my health information. I understand that this organization has the right to change its “Notice of Privacy Practices” from time to time and that I may contact this organization at any time at the address above to obtain a current copy of this “Notice of Privacy Practices.”

I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment, or healthcare operations. I also understand you are not required to agree to my requested restrictions, but if you do not agree, then you are bound to abide by such restrictions.

Patient Name: ________________________________________________________

Patient representative: ________________________________________________________

Signature: ________________________________________________________

Date: _______________________________________________