YOUR RIGHTS REGARDING YOUR PHI. You have the following rights regarding PHI we maintain about you. To exercise any of these rights, please submit your request in writing to our Privacy Officer at: 000 X. Xxxxxxxxx Xxxx, Xxxxx 000, Xxxxxxx, XX 00000.
Appears in 3 contracts
Samples: Therapist Client Agreement, Therapist Client Agreement, www.tripastoralcounseling.org
YOUR RIGHTS REGARDING YOUR PHI. You have the following rights regarding PHI we maintain about you. To exercise any of these rights, please submit your request in writing to our Privacy Officer at: Xxxxx Xxxxxx PsyD, MFT 00000 Xxxxxxx Xxx Xxxxx 000 X. Xxxxxxxxx XxxxAuburn, Xxxxx 000, Xxxxxxx, XX 00000.CA 95603
Appears in 1 contract
Samples: drsusanlandesmft.com
YOUR RIGHTS REGARDING YOUR PHI. You have the following rights regarding your personal PHI we maintain about youmaintained by our office. To exercise any of these rights, please submit your request in writing to our Privacy Officer at: 000 X. Xxxxxxxxx XxxxOfficer,_XXXX XXXXXX , at 0000 X, Xx, Xxx 00, Xxxxx 0000, XxxxxxxXxxxxxxxxxxxxx, XX Xxxxx 00000.
Appears in 1 contract
Samples: Professional Services Agreement
YOUR RIGHTS REGARDING YOUR PHI. You have the following rights regarding PHI we maintain about you. To exercise any of these rights, please submit your request in writing to our Privacy Officer at: 000 X. Xxxxxxxxx Xxxx, Xxxxx 000, Xxxxxxx, XX 00000.at :
Appears in 1 contract
Samples: For Care Management Services
YOUR RIGHTS REGARDING YOUR PHI. You have the following rights regarding PHI we maintain about you. To exercise any of these rights, please submit your request in writing to our Privacy Officer at: 000 X. Xxxxxxxxx Xxxx, Xxxxx 000, Xxxxxxx, XX 00000.at [Insert Contact Information]:
Appears in 1 contract
Samples: Service Agreement
