Notice of Privacy Practices

  • Patient Acknowledgement of Receipt of Privacy Practices Notice

  • I hereby acknowledge that I have reviewed and had the opportunity to receive a copy of Montclair Radiology's Notice of Privacy Practices explaining:
    -How Montclair Radiology will use and disclose my Protected Health Information.
    -My privacy rights in regards to my Protected Health Information.
    -Montclair Radiology's obligation concerning the use and disclosure of my Protected Health Information.

    I understand that the Notice of Privacy Practices may be revised from time to time and that I am entitled to receive a copy of any revised Notice of Privacy Practices upon request.
    I also understand that if I have any questions or complaints, I may contact:

    Montclair Radiology, ATTN: Privacy Officer, Telephone: 973-284-0038

    You may also contact the Secretary of the U.S. Department of Health and Human Services with any concerns regarding our privacy and security policies and procedures. Please contact our office for information on how to contact the U.S. Department of Health and Human Services.

  • Date Format: MM slash DD slash YYYY
  • In addition to myself and my physician, I hereby authorize the following individual access to my records.

  • Date Format: MM slash DD slash YYYY
  • This authorization is valid for 1 year or can be revoked at any time in writing.

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