The purpose of the disclosure authorized in this consent is to receive recovery support. I understand that my alcohol and/or drug treatment records are protected under the Federal regulations governing Confidentiality of Alcohol and Drug Abuse Patient Records, 42 C.F.R. Part 2, and the Health Insurance Portability and Accountability Act of 1996 (HIPAA), 45 C.F.R. Pts. 160 &164 and cannot be disclosed without my written consent unless otherwise provided for in the regulations. I also understand that I may revoke this consent at any time. I understand and agree to the following: 1. I grant permission for a volunteer to call me at the above phone number, email, and/or address to support me in my recovery. 2. Each time the volunteer calls, he/she will be asking me how my recovery is progressing and if I am in need of additional support (i.e., meetings in area, recovery community centers, safe/sober housing, social events, other resources). 3. At the time of the call, if I am in need of a referral to a treatment program or detox unit, I will be assisted in finding a program, if I so desire. 4. If at any time I decide not to take part in this program, I will contact the center or tell the volunteer when he/she calls.

You are required to complete additional consent forms. Click Next to continue to the next page.

Authorization and Waiver for RUR Program Transportation

I,________________ (Print client’s name) DOB: ________________ hereby authorize

I authorize in times of need, the CPRS to transport myself and any belongings in their personal vehicles. I understand that I am expected to follow all applicable laws regarding riding and possessions in a motor vehicle. I also understand that I must be completely sober.

I have read and understand:

1. I will travel in a motor vehicle driven by a licensed CPRS and I will wear a safety belt during all travel.
2. Riding in a motor vehicle and transporting belongings presents various risks such as personal injury/accident or difficulty transporting requested belongings;
3. The participants belongings that are transported in the vehicle MAY NOT include medications, valuable items (unless previously approved by Director), controlled substances, alcohol and in total must be able to be carried by one person in one trip.

Initial Each Statement

I hereby attest and verify that I have been advised of the potential risks and I have full knowledge of risks involved in riding in CPRS vehicle. I assume any expenses and liability incurred in the event of an accident, illness or other incapacity.

As a condition for the transportation received, I, for myself, my child, my executors, further agree to release and relieve the CPRS and RISE UP Recovery from any claim that I might have myself or that I could bring on my behalf with regard to any damages, demands or actions whatsoever, including those based on negligence in any manner arising out of transportation received.

I have read this entire waiver and authorization form, I fully understand it’s terms and conditions and I agree to be legally bound by these terms and conditions.

Client Bill of Rights Notification

All clients of Rise Up Recovery are afforded certain rights under federal and state laws. Rise Up Recovery will not modify these rights, and no client will be required to waive any of these rights, except as permitted or required by federal or state law.

A written copy of these rights will be posted in a prominent area where Rise Up Recovery clients and staff members to see, and a copy will be provided to each client upon admission, and thereafter upon request. Rise Up Recovery staff members understand these rights, will uphold them, and will provide assistance upon your request.

Health Care Bill of Rights (MN Statutes, Section 144.651 and 144.652)

The rights provided under the Health Care Bill of Rights (Sec 144.651), are as follows:

• Information about your rights will be given to you upon your admission into Rise Up Recovery and throughout your stay upon request. (Subd 4)
• Reasonable accommodations will be made for people who have communication disabilities and those who speak a language other than English. (Subd 4)**
• You have the right to request release, and Rise Up Recovery will provide a list of the names and telephone numbers of individuals and organizations that provide advocacy and legal services for patients in residential programs. (Subd 4)
• If you are a minor,16 years or older, you have the right to leave the facility within 72 hours (exclusive of Saturdays, Sundays, and Holidays) of making a request for release as provided in MN Statutes Sec 253B.04 Subd.2, and Rise Up Recovery will provide a list of the names and telephone numbers of individuals and organizations that provide advocacy and legal services for patients in residential programs. (Subd 4)
• Courteous treatment and respect for their individuality by all employees. (Subd 5)
• Appropriate health care based on individual needs to reach highest level of physical and mental functioning. (Subd 6)
• Physician's identity will be shared in writing including name, business, address, phone number and specialty of any kind. (Subd 7)
• Relationship with other health services will be disclosed at request. (Subd. 8)
• Information about treatment including diagnosis, alternatives, risks and prognosis as required by physician’s legal duty to disclose. (Subd 9)
• May participate in planning treatment. (Subd 10)
• The right to be cared for with reasonable regularity and continuity of staff. (Subd 11)
• The right to refuse care. Staff will inform the client of the likely results of their refusal and document this. (Subd 12)
• The right to participate in experimental research. (Subd 13)**
• The right to privacy of medical and personal care program. (Subd 15)
• The right to confidentiality of identity and records (Subd. 16, and 42 C.F.R. Part 2)
• The right to be informed of services available including their rates and charges. Rise Up Recovery will ensure clients are helped in gaining information about Medicare or medical assistance programs that may pay for services. (Subd. 17).
• The right to prompt and reasonable responses to their questions and requests. (Subd 19)
• The right to personal privacy, individuality and cultural identity as related to their social, religious and psychological well-being. (Subd. 19)**
• The right to voice grievances without threat of discharge, discrimination or retaliation. (Subd. 20)
• The right to communicate privately with persons of their choice. This includes the right to mail (unopened) and access to a telephone. (Subd 21).**
• The right to their personal clothing and possessions. (Subd 22)
• The right to not perform labor or services for the facility unless they are for therapeutic purposes and goal-related in their individual medical record. (Subd 23).**
• The right to choose suppliers and oversee their financial affairs. (Subd 24 and 25).**
• The right to associate with whom they want to associate with including family members and having meetings on site. (Subd 26 and 27). **
• The right to be married and assured privacy for visits. (Subd 28)**
• The right to be notified of transfers and discharges in writing and the right to contest this. (Subd. 29)**
• The right to protection and advocacy services. (Subd 30)
• Minors have the right to be free from physical restraint and isolation except in emergency situations where the likelihood the client would harm self or others. (Subd 31)
• The right to a written treatment plan. (Subd 32)

** Bullet points marked with this asterisk may be subject to facility rules.

All Rise Up Recovery policies, as well as any state and local agency inspection findings, and any further explanation of these written rights, will be made available to all clients upon reasonable request to Rise Up Recovery and any staff member.

Contact Information for Medical Inquiries and Complaints:

Questions or concerns regarding medical care may be made to any Rise Up Recovery nurse. Contact information will be made available upon request. Clients may also contact the Minnesota Board of Medical Practice:

Address:

Minnesota Board of Medical Practices
2829 University Ave SE,
Suite 500
Minneapolis, MN 55414

Phone:

(612) 617-2130

Clients who wish to file a complaint regarding any perceived violation of the rights included herein, may contact the Minnesota Office of Health Facility Complaints:

Address:

Health Regulation Division
Golden Rule
Building 85 East 7th Place
St Paul, MN 55101

Phone:

(651) 201-4200

Consent for Telehealth

Rise Up Recovery 507 Vermillion Street Hastings, MN 55033

CONSENT FOR TELEHEALTH CONSULTATION

1. I understand that my health care provider wishes me to engage in a telehealth consultation.
2. My health care provider explained to me how the video conferencing technology that will be used to affect such a consultation will not be the same as a direct client/health care provider visit due to the fact that I will not be in the same room as my provider.
3. I understand that a telehealth consultation has potential benefits including easier access to care and the convenience of meeting from a location of my choosing.
4. I understand there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties. I understand that my health care provider or I can discontinue the telehealth consult/visit if it is felt that the videoconferencing connections are not adequate for the situation.
5. I have had a direct conversation with my provider, during which I had the opportunity to ask questions in regard to this procedure. My questions have been answered and the risks, benefits and any practical alternatives have been discussed with me in a language in which I understand.

CONSENT TO USE THE TELEHEALTH BY Rise Up Recovery

Telehealth by Rise Up Recovery Zoom account is the technology service we will use to conduct telehealth videoconferencing appointments. It is simple to use and there are no passwords required to log in. By signing this document, I acknowledge.

1. Telehealth by Rise Up Recovery Zoom account is NOT an Emergency Service and in the event of an emergency, I will use a phone to call 911.
2. Though my provider and I may be in direct, virtual contact through the Telehealth Service, neither Rise Up Recovery Zoom account nor the Telehealth Service provides any medical or healthcare services or advice including, but not limited to, emergency or urgent medical services.
3. The Telehealth by Rise Up Recovery Zoom account Service facilitates videoconferencing and is not responsible for the delivery of any healthcare, medical advice or care.
4. I do not assume that my provider has access to any or all of the technical information in the Telehealth by Rise Up Recovery Zoom account Service – or that such information is current, accurate or up-to-date. I will not rely on my health care provider to have any of this information in the Telehealth by Rise Up Recovery Zoom account Service.
5. To maintain confidentiality, I will not share my telehealth appointment link with anyone unauthorized to attend the appointment.

By signing this form, I certify:

That I have read or had this form read and/or had this form explained to me.

That I fully understand its contents including the risks and benefits of the procedure(s).

That I have been given ample opportunity to ask questions and that any questions have been answered to my satisfaction.

Grievance Procedure

1.0 PURPOSE

To define the participant grievance process.

2.0 PERSONS AFFECTED

All employees, contractors, and volunteers of RISE UP RECOVERY

3.0 POLICY

RISE UP RECOVERY will provide guidelines for participants or their representatives to file a grievance regarding any part of their care while at RISE UP RECOVERY

4.0 PROCEDURE(S)

The following steps are guidelines for RISE UP RECOVERY participants or their authorized representatives to follow if they desire to file a grievance regarding any aspect of their care while a participant of the RISE UP RECOVERY program. RISE UP RECOVERY staff must assist any participant desiring to file a grievance in developing and processing the grievance. This grievance process will also be made available to former participants:

1. How to File a Grievance
   1. The person receiving services or the person’s authorized or legal representative:
      1. should talk to a staff person that they feel comfortable with about their complaint or problem;
      2. clearly inform the staff person that they are filing a formal grievance and not just an informal complaint or problem; and
      3. may request staff assistance in filing a grievance.
   2. If the person or person’s authorized or legal representative does not believe that their grievance has been resolved, they may bring the complaint to the highest level of authority in this program.
      • That person is Tiffany Neuharth, Executive Director.
      • She may be reached at 651-319-0122 or tiffany@riseuprecoverymn.com
2. Response by the Program
   1. Upon request, staff will provide assistance with the complaint process to the service recipient and their authorized representative. This assistance will include:
      1. the name, address, and telephone number of outside agencies to assist the person; and
      2. responding to the complaint in such a manner that the service recipient or authorized representative’s concerns are resolved.
   2. This program will respond to grievances that affect the health and safety of service recipients within three days.
   3. All other complaints will be responded to within 14 calendar days of the receipt of the complaint.
   4. All complaints will be resolved within 30 calendar days of the receipt.
   5. If the complaint is not resolved within 30 calendar days, this program will document the reason for the delay and a plan for resolution.
   6. Once a complaint is received, the program is required to complete a complaint review. The complaint review will include an evaluation of whether:
      1. related policy and procedures were followed;
      2. related policy and procedures were adequate;
      3. there is a need for additional staff training;
      4. the complaint is similar to past complaints with the persons, staff, or services involved, and there is a need for corrective action by Rise Up Recovery to protect the health and safety of persons receiving services.
   7. Based on this review, Rise Up Recovery will develop, document, and implement a corrective action plan designed to correct current lapses and prevent future lapses in performance by staff or Rise Up Recovery, if any.
   8. The program will provide a written summary of the complaint and a notice of the complaint resolution to the person and case manager that:
      1. identifies the nature of the complaint and the date it was received;
      2. includes the results of the complaint review and
      3. identifies the complaint resolution, including any corrective action.
3. The complaint summary and resolution notice must be maintained in the person’s record.

Additionally, the participant may also contact the following organizations regarding grievances:

Department of Human Services
Licensing Division
444 Lafayette Road, St. Paul, MN 55142
Phone:(651) 431-6500

Office of Ombudsman for Mental Health
and Developmental Disabilities
121 7th Place East, Ste 420
St. Paul, MN 55101-2117
Phone:(651) 757-1800

Office of Quality Monitoring
Joint Commission on Accreditation of Healthcare Organizations
One Renaissance Boulevard
Oakbrook Terrace, IL 60181
Phone: 1-800-994-6610

Minnesota Certification Board
PO Box 586
Wyoming, MN 55092
Phone: 763-434-9787

Department of Health Facilities Complaints
651-201-4201

NOTICE OF PRIVACY PRACTICES

THIS NOTICE RELATES TO YOUR PRIVACY AND CONFIDENTIALITY RIGHTS UNDER FEDERAL AND STATE LAW. PLEASE REVIEW IT CAREFULLY BEFORE SIGNING BELOW.

Rise Up Recovery strictly adheres to all federal and state confidentiality protections including, but not limited to, those set forth in Title 42 C.F.R. Part 2, the Health Insurance Portability and Accountability Act (“HIPAA”), and all related Minnesota statutes.

Confidentiality under Title 42 C.F.R. Part 2. Rise Up Recovery is governed by the federal laws and regulations contained in Title 42 C.F.R. Part 2. In general, Rise Up Recovery may not use or disclose any personal information (whether recorded or not) regarding a prospective, current and/or former Rise Up Recovery client. Such information includes, but is not limited to, the identity, diagnosis, prognosis, treatment or referral of any prospective, current and/or former Rise Up Recovery client, unless the client has consented in writing (on a form that meets the requirements established by the regulations), or an exception, specified in the regulations, applies. In addition, Rise Up Recovery may not acknowledge that any client attends this treatment program to any individual or entity outside of Rise Up Recovery, nor may Rise Up Recovery disclose any information which may identify a client as an alcohol or drug abuser, including any inference to the client’s identity (“Patient Identifying Information” or “PII”), unless an exception applies (specified in the regulations). Any disclosure, permitted under Title 42 C.F.R. Part 2, must then be limited to that which is necessary to carry out the purpose of the disclosure or permitted exception.

Confidentiality under HIPAA. HIPAA also provides protection of your personal health information (“ Protected Health Information” or “PHI”) whether or not you are applying for or receiving services for drug or alcohol abuse. HIPAA remains applicable to Rise Up Recovery, and particularly as it relates to the operations of Rise Up Recovery and safeguards which are implemented to limit any risk of unauthorized disclosure.

Our Pledge to Protect Your Privacy and Confidentiality:

The security of your identity, status of enrollment, and any personal information about you is of great importance to Rise Up Recovery. Rise Up Recovery will strictly comply with federal and state laws including, but not limited to, the following:

• We will not use or disclose your PII or PHI for any reason without your written authorization, unless an exception described in this Notice applies.
• We will protect any and all records that have been generated within Rise Up Recovery, or received by outside sources, related to your identity, diagnosis, prognosis, treatment, referral, payment history, or any other PII or PHI.
• We will notify you about how we protect any and all information related to you.
• We will explain how, when and why we use or disclose your PII or PHI.
• All exceptions to the restriction on disclosure are provided below, for your information.
• We will only use or disclose your protected health information as we have described in this Notice.
• We will abide by the terms of this Notice.
• We will notify you if a discrepancy arises between you and Rise Up Recovery related to how your information is used or disclosed.
• We will notify you of any breach or unauthorized disclosure of any and all information about you.
• We will accommodate reasonable requests that you may have related to the method of communication used for authorized disclosures.
• We will allow you access to your records.

Modification of any terms of this Notice may be made only as permitted by law. Any updated provisions will be posted in a prominent location within your facility.

SUMMARY OF YOUR CONFIDENTIALITY PROTECTIONS:

1. In general, all Rise Up Recovery staff are forbidden from disclosing your identity, presence in the facility, and/or your personal health or treatment information, including associated records, unless you have provided written authorization.
2. There are a limited number of circumstances under which Rise Up Recovery staff may acknowledge that a client is enrolled in a Rise Up Recovery program, or make any disclosure of information identifying a client as an alcohol or drug abuser to an individual or entity not within the program. Those circumstances include the following:
   1. Pursuant to your written consent;
   2. Pursuant to a proper court order;
   3. Disclosure made to medical personnel in a medical emergency, or to qualified personnel for certain research, audit, or program evaluation;
   4. Any communication between personnel of Rise Up Recovery having a need for the information (related to program operations); or
   5. Certain situations involving the Veterans Administration and Armed Forces. Please refer to 42 C.F.R. Part 2 Sec 2.12(c) for further understanding.
3. Any violation of Title 42 C.F.R. Part 2 by Rise Up Recovery is a crime, and suspected violations may be reported to appropriate authorities in accordance with Title 42 C.F.R. Part 2.
4. These restrictions do not protect the disclosure of information if it is related to a crime committed by a client either at Rise Up Recovery or against any person who works at Rise Up Recovery, or about any threat to commit such a crime.
5. These restrictions do not protect the disclosure/reporting of information to appropriate state or local authorities related to suspected child abuse or neglect under state law.
6. Any further information can be found within the provisions of Title 42 C.F.R. Part 2.

USE/DISCLOSURE OF YOUR INFORMATION WITHOUT YOUR AUTHORIZATION

In general, we must first obtain your written consent/authorization to disclose information about you to persons or entities outside of Rise Up Recovery. However, in a limited number of circumstances, we will be permitted by law to disclose your PII or PHI without first obtaining your written authorization. Those circumstances are as follows:

• Communication between Rise Up Recovery Staff. Communication between staff of Rise Up Recovery is permitted without your consent when such communication relates to your treatment at Rise Up Recovery. This pertains to any department in any location of Rise Up Recovery as long as the communication relates to your treatment and continued care.
• Photographs/Recordings. Photographs for identification, or recordings by video or audio technology to assist, either, your therapy/treatment, or staff member supervision, and used only within Rise Up Recovery, is considered communication between staff, and is allowed without your written consent. However, if any actions made by you are intended to be captured by photograph, recorded by camera or any other technology, and used for any purpose other than the internal operations of Rise Up Recovery, you must be informed and given the right to refuse prior to the capture of any such photo, recording, etc. Your written authorization is required for use or disclosure of any such photograph, recording, etc., that is intended to be used for purposes other than the internal operations of Rise Up Recovery.
• Mandatory Reporting of Maltreatment of a Minor. Any staff member of Rise Up Recovery who knows, or has reason to believe, that any child has been maltreated, may report such matter, with or without your written consent. This applies to any known or suspected prenatal exposure to controlled substances. Please note: most staff members of Rise Up Recovery are required by law to report any suspected child abuse.
• Qualified Service Organizations. Rise Up Recovery may exchange information related to your PII or PHI with a Qualified Service Organization acting in accordance with its services to Rise Up Recovery. Qualified Service Organizations must first enter into a contract with Rise Up Recovery requiring their compliance with all federal and state laws related to confidentiality. Information exchanged between Rise Up Recovery and a Qualified Service Organization is limited to that which is necessary to provide such services. Examples of a Qualified Service Organization are: on-sight health care providers, or laboratory screening (drug testing) providers.
• Healthcare Data. Rise Up Recovery may disclose your PII or PHI to qualified agency personnel for certain research, audit, or program evaluation. Such information or data is strictly limited to the agency’s approved objectives. Examples would include collecting enrollment data to gauge increases or decreases in service needs, or auditing aspects of Rise Up Recovery so the agency can accurately monitor the healthcare system.
• Incompetent and Deceased Patients. In the event an individual is determined to be incompetent or dies, we may obtain authorization of a personal representative, guardian or other person authorized by applicable state law in accordance with 42 C.F.R. Part 2. We may disclose protected health information to a coroner, medical examiner or other authorized person under laws requiring the collection of death or other vital statistics, or which permit inquiry into the cause of death.
• Judicial and Administrative Proceedings. We may disclose your PII or PHI in response to a court order that meets the requirements of Title 42 C.F.R. Part 2, concerning Confidentiality of Alcohol and Drug Abuse Patient Records.
• Law Enforcement Purposes. We may disclose your PII or PHI to the police or other law enforcement officials if you commit a crime on the premises or against Rise Up Recovery personnel, or threaten to commit such a crime.
• Medical Emergencies. We may disclose your protected health information to medical personnel to the extent necessary to meet a bona fide medical emergency (as defined by 42 C.F.R. Part 2).
• Minors. We may disclose to a parent or guardian or other person authorized under state law to act on behalf of a minor, those facts about a minor which are relevant to reducing a threat to the life or physical well-being of the minor or any other individual, if Rise Up Recovery determines that the minor applicant lacks capacity to make a rational decision and the minor’s situation poses a substantial threat to the life or physical well-being of the minor or any other individual which may be reduced by communicating relevant facts to such person.
• Public Health. We may report to public health authorities the exposure, or risk of exposure, to certain communicable diseases or risks of contracting or spreading a disease or condition.
• Required by Law. We may disclose your protected health information when such disclosure is required or permitted by federal, state or local laws.

YOUR INDIVIDUAL RIGHTS

1. Right to Revoke Your Authorization.

   If you give us a written authorization to disclose information, you may revoke it at any time, whether in writing or orally (in person). If you revoke your permission, we will stop using or disclosing your protected health information in accordance with that revocation, except to the extent that we have already relied on it.

2. Free from Retaliation.

   In addition to your rights to privacy and confidentiality, Rise Up Recovery will honor and support your right to make a complaint or file a grievance internally, or make a complaint to a state or federal agency. All Rise Up Recovery clients should feel uninhibited from making such a claim, and will be free from interference, coercion, discrimination, retaliation or reprisal, including any threat of discharge.

3. Right to Access and Copy Your Protected Health Information.

   You have the right to access and receive a copy or a summary of your records at Rise Up Recovery. We ask that your request be made in writing. We may charge a reasonable fee. There might be limited situations in which we may deny your request. Under these situations, we will respond to you in writing, stating why we cannot grant your request and describing your rights to request a review of our denial.

4. Right to Request an Amendment of Your Protected Health Information.

   You have the right to request amendments to the PII or PHI about you that we maintain and use to make decisions about you. We ask that your request be made in writing and must explain, in as much detail as possible, your reason(s) for the amendment and, when appropriate, provide supporting documentation. Under limited circumstances we may deny your request. If we deny your request, we will respond to you in writing stating the reasons for the denial. You may file a statement of disagreement with us. You may also ask that any future disclosures of the PII or PHI under dispute include your requested amendment and our denial to your request.

5. Right to Request Restrictions on Uses and Disclosures of Your Protected Health Information.

   You have the right to request that we restrict our use or disclosure of your protected health information. We ask that your request be made in writing. The request will be upheld, subject to the exceptions listed above.

6. Right to Request an Accounting of Disclosures of Protected Health Information.

   You have the right to request a listing of certain disclosures we have made of your protected health information. We ask that your request be made in writing. You may ask for disclosures made up to six (6) years before the date of your request. We will provide you one accounting in any 12-month period free of charge.

7. Right to Receive a Copy of This Notice.

   You have the right to request and receive a paper copy of this Notice at any time. We will make this Notice available in electronic form and post it in our web site.

8. Right to Notice of Breach.

   You have the right to immediate notice of a “Breach” involving any PII or PHI, as specifically defined under the federal law commonly known as the HITECH Act. Not all unauthorized uses or disclosure of your protected health information will be considered a Breach under the law. This notice will be sent as required under the law. If you authorize us to communicate with you by e-mail we may e-mail you notice of any Breach. In most other cases we will contact you by phone and send you the required notice in by mail.

9. Right to Electronic Copy of Electronic Health Record.

   You have the right to ask for an accounting of disclosures of your PII or PHI from an electronic health record. You may request an accounting for a period of three (3) years prior to the date the accounting is requested. You also have the right to ask our Qualified Service Organizations for an accounting of their disclosures. In addition, you have the right to request an electronic copy of that which is maintained in our electronic health record.

   CONTACT INFORMATION FOR MEDICAL INQUIRIES AND COMPLAINTS:

   Questions or concerns regarding medical care may be made to any Rise Up Recovery nurse. Contact information will be made available upon request.
   You may also contact the Minnesota Board of Medical Practice:

   Address:

   Minnesota Board of Medical Practices
   2829 University Ave SE, Suite 500
   Minneapolis, MN 55414
   

   Phone:

   (612) 617-2130

   If you wish to file a complaint regarding any perceived violation of your rights, you may contact the Compliance Manager of Rise Up Recovery (provided below), or the Minnesota Office of Health Facility Complaints:

   Address:

   Health Regulation Division
   Golden Rule
   Building 85 East 7th Place
   St Paul, MN 55101

   Phone:

   (651) 201-4200

   If you have any questions or concerns regarding your rights and/or the privacy practices set forth above, you may contact the Compliance Manager of Rise Up Recovery. We will provide any additional contact information upon request.

   COMPLIANCE MANAGER CONTACT INFORMATION:

   Kevin Joyce 847-363-1712
   kevinjjoyce6@gmail.com

   EFFECTIVE DATE OF THIS NOTICE

   This notice went into effect date document is signed.

   Acknowledgment of Receipt of Privacy Notice

   Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you have certain rights regarding the use and disclosure of your protected health information. By checking the box below, you are acknowledging that you have received a copy of HIPAA Notice of Privacy Practices.