Notice of Privacy Practices Form |
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Please read the Notice of Privacy Practices Form below. After you have reviewed, please sign and submit the form. If you prefer to fill out a physical form, we invite you to download the Notice of Privacy Practices Form, complete and fax it to us at (612) 706-5555.
You may also fill out the form on your computer and upload a completed PDF version in the upload form box below. Please print completed documents for your personal records.
You may also fill out the form on your computer and upload a completed PDF version in the upload form box below. Please print completed documents for your personal records.
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Please download the Notice of Privacy Practices Form, read, sign and save. You can print it and fax it us a signed copy at (612) 706-5555 or submit by uploading your completed document by using the upload form. Please print completed documents for your personal records.
Data Privacy We invite you to visit our Privacy Practices page to review our policies regarding the security of your information. This page describes how medical information about you may be used and disclosed and how you can get access to this information. Your Personal Health Information (PHI) may be used and disclosed to those who are involved in your care for the purpose of providing, coordinating, or managing your services. This includes consultation with clinical supervisors or other team members. Your authorization is required to disclose PHI to any other care provider not currently involved in your care. If you have questions or need more information, please contact us by calling (612) 789-1236 or email rehabclinic@actg.org. |
