F:ast Ride Medical ItacSolo*, PI.I.0 Sites cis D. Wolff M.D. Ph.D. 170 E nr• fit_ Nen York, NV 10073 HIPAA PRIVACY NOTICE • I acknowledge that I have been given a copy of the Practices - HIPAA Privacy Notice" which describes the Practice's obbgations to ensure the privacy of ay health information. The HIPAA Privacy Notice also describes how the Practice may use and disclose my health information for treatment, payment and health care operations. I know that I have the right to review the Practice's NIPAA Privacy Notice and to ask questions about It. I understand the Practice is required to maintain the privacy of my wale, information In accordance with the terms of its rlIPAA Privacy Notice. • I further acknowledge that the Practice can change its HIPAA Privacy Notice in the future, and 'helicon receive a copy of the Practices current Privacy Notice at any tante by contacting the Privacy Officer. • I understand that I have a right to request that the Practice restrict its uses and disclosures of my health information for treatment, payment, or health care operations. If my restrictions are accepted by the Practice, these restrictions will be binding on the Practice. I also understand that the Practice is not required to agree to my requested restrictions. • I RAINS 'squad any restrictions on the Practice's use or disclosures of my health Information for treatment. payment or health care operations. • I de request specific restrictions, as listed below, on the Practice's use or disclosures of my hearth information for treatment, payment or health care operations. • By signing this form, I consent to the Practice's use and disclosure of my health information for treatment, payment and healthcare operations. I understand that I have the right to revoke this consent at any time a writng, but if I do, my revocation wifi not influence any ections the Practice has eroady taken in reliance on this consent. RSORINUatI911 Jo Obtain or Release Medic