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What is your role? What type of practice are you affiliated with?

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First Name (of person filling out form) Last Name (of person filling out form) Email Address (of person filling out form) Practice Name (AS IT SHOULD APPEAR TO PATIENTS) Street Address City State Zip Code Office number Practice email Is your practice affiliated with the MBSAQIP? Do you have onsite registered dietitians?
Who does your pre-operative education?
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I understand that under the Health Insurance Portability & Accountability Act of 1996 (“HIPAA”), I have certain rights to privacy regarding my protected health information. I understand this information can and will be used to: Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and/or indirectly; Obtain payment from third-party payers; and Conduct normal healthcare operations such as quality assessments and physician certifications.

I acknowledge I understand your Notice of Privacy Practices uses and disclosures of your health information. I understand this organization has the right to change its Notice of Privacy Practices from time to time, and I may contact this organization at any time at the address below to obtain a current copy of the Notice of Privacy Practices.

I understand I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or health care operations. I also understand you are not required to agree to my requested restrictions, but if you do agree, you are bound to abide by such restrictions.

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