Iris Family Support Center’s Notice of Privacy Practices has been offered to me. I understand I have the right to review the Notice of Privacy Practices prior to signing this document and by signing this document, I acknowledge only that I have been offered the Notice of Privacy Practices or have declined the offer.
Iris Family Support Center reserves the right to change the privacy practices that are described in the Notice of Privacy Practices.
I may obtain a revised notice of privacy practices by calling the office and requesting a revised copy be sent in the mail or asking for one at the time of my next appointment.
I authorize the following person(s) minimal access (does not include copies of medical records) to my protected health information (PHI):
Patient's Signature: For authorization to release limited PHI to the above listed individuals
I further authorize Iris Family Support Center to communicate with me electronically through email at the following email address:
I understand that this email communication is not secured by encryption, therefore it is not considered secure or private communication. Iris Family Support Center will not be held responsible for further disclosure of your information sent via unencrypted email.
Patient's Signature: For authorization to communicate with me electronically through email