Questions or Complaints. If you have questions about this notice or think that we have not protected your private health information and you wish to complain about it, please contact: Xxxxxxx Xxxxxxx, Ph.D. at (000) 000-0000. You can also complain to the Federal Government by writing to the: Office for Civil Rights U.S. Department of Health and Human Services 000 Xxxxxxxxxxxx Xxxxxx, X.X. Room 509F, HHH Building Washington, D.C. 00000-0000 Or by calling the Office for Civil Rights at (000) 000-0000 By signing this form, you are acknowledging that you have received a copy of this notice (NOTICE OF USE OF PRIVATE HEALTH INFORMATION) Patient Signature Date Parent/Guardian Signature (if necessary) Date OUR FINANCIAL POLICY Thank you for choosing Pacific Pain and Wellness Group for your medical care. Our goal is to provide you with the highest quality of medical care and service. We feel it is helpful and important that you understand our billing process. We are happy to bill your insurance for any services provided at our offices. However, this is a courtesy service to you and you are responsible for any costs incurred during your course of treatment. Each patient must complete the Patient Information Record which includes all demographic information including your insurance. We must have this information completed before you see the doctor on your first visit.
Questions or Complaints. If you have a question or complaint about your privacy rights, please contact Xx. Xxxx by phone at 000-000-0000 or by mail at 4971 East I-00 Xxxxxxx Xxxx Xxxxx, Xxxxx Xxxx Xxxxxxxxxx Xxxxxxxx; Xxxxxx Xxxx, XX 00000. If Xx. Xxxx is unable to resolve your complaint to your satisfaction, you may send a written complaint to the Office of Civil Rights, U.S. Department of Health & Human Services, 000 Xxxxxxxxxxxx Xxxxxx, X.X., Xxxx 000X, XXX Xxxxxxxx, Xxxxxxxxxx, X.X. 20201. We will not retaliate against you for filing a complaint. This notice became effective on January 2, 2020. Verification of Understanding of PROFESSIONAL SERVICES AGREEMENT and NOTICE OF PRIVACY RIGHTS AND POLICIES I have read, understood and received or been offered a copy of the PROFESSIONAL SERVICES AGREEMENT AND NOTICE OF PRIVACY RIGHTS AND RESPONSIBILITIES dated 1/2/2020 as it is presented for compliance with the Health Insurance Portability & Accountability Act of 1996, as amended and supplemented (HIPAA) and with the Texas State Board of Psychology Examiners Rules of Practice and as the written explanation of the privacy policies of Xx. Xxxx Xxxx’s practice in clinical psychology. Signature Date Printed Name Additional Signature (if needed) Date Printed Name OPTIONAL - AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION Date of Birth: Patient’s Name:
Questions or Complaints. You can direct any questions or complaints about the use or disclosure of your personal data to us at xxxxx@xxxxxxxx.xxx. We will investigate and attempt to resolve any complaints or disputes regarding the use or disclosure of personal data within 45 days of receiving your complaint.
Questions or Complaints. If you have a question or complaint regarding the Site, please contact us at: xxxx@xxxxx-xxxxx.xx
Questions or Complaints. 15.1 Questions about the Terms and Conditions should be addressed to: Xxxx of Higher Education Loughborough College Radmoor Road Loughborough Leicestershire LE11 3BT
Questions or Complaints. If you have questions or complaints about our broadband Internet access service you should first visit our website at: xxx.xxxxxxxxxxx.xxx. If the question or complaint is not resolved on the web, you may contact one of our customer service representatives at 000-000-0000. We find that most customer concerns or disputes can be resolved through our customer service representatives. If the question or complaint is still not resolved you may contact Naked Mobile’s Chief People Officer at XXX@xxxxxxxxxxx.xxx. However, any customer disputes that cannot be resolved without third-party intervention will be resolved by binding arbitration in accordance with the terms of our service agreement, which can be found here: xxx.xxxxxxxxxxx.xxx.
Questions or Complaints. If you have questions about this notice, or believe that your privacy rights have been violated, please contact our Privacy Officer, Xxxxxx Xxxxx at 0-000-000-0000 or by email at privacy.officer@ xxxxxxxxxxxxxxxxxxx.xxx. You have the right to file a written complaint with us or directly to the secretary of Health and Human Services. You should know that there would be no retaliation for your filing a complaint. PRIVACY POLICIES AND PROCEDURES: PATIENT ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF HEALTH INFORMATION PRIVACY PRACTICES Effective Date: January 1, 2003 Purpose: To publish the policies and procedures to implement the requirements of the Final HIPAA (Health Insurance Portability and Accountability Act) Privacy Rule with regard to obtaining the patient’s acknowledgment of receipt of a copy of MCC’s Notice of Health Information Privacy Practices. The Privacy Rule (as amended at section 164.520(c)(2)(ii)) states: "Except in an emergency treatment situation, [health care providers having a direct care rela- tionship with a patient] must make a good faith effort to obtain a patient’s written acknowledg- ment of receipt of the notice provided in accordance with paragraph (c)(2)(i) of this section, and if not obtained, document its good faith efforts to obtain such acknowledgment and the reason why the acknowledgment was not obtained." Policy: All MCC physicians and health care providers are required by HIPAA to provide each patient with a copy of MCC’s Notice of Health Information Privacy Practices and to make a “good faith effort” to obtain the patient’s written acknowledgment that they have been provided with a copy of the Notice. Procedure:
Questions or Complaints. 16.1 Questions about the Terms and Conditions should be addressed to: Careers and HE Advisor Xxxxxxxxxx College Thornborough Road Coalville Leicestershire LE67 3TN
Questions or Complaints. If you have a question or a complaint about this Privacy Notice or information handling processes, you can send us an email to xxxx@XxxxxxXxxx.xxx
Questions or Complaints. 15.2.1. We always want to hear from you if there is something you are unhappy with or that you think we can do better. We can be contacted at xxxx@xxxxxxxxxxx.xxx or by phone at (000) 000-0000 on weekdays. The opening hours of our customer service can be found on the Site or in the App under “Contact”.
