Veteran Owned and Operated

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Sheila L. Uridil, MSN, APRN, AGACNP-BC, ANP-BC
Joseph E. Uridil IV, MSN, APRN, AGACNP-BC
NeighborhoodHealthcareJ.S@gmail.com

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HIPAA Acknowledgment Form

Notice of Privacy Practices

Federal law requires that we provide you with information about how your health information may be used and disclosed, and how you can access that information.

Our Notice of Privacy Practices explains:

  • How we may use and share your health information for treatment, payment, and healthcare operations.
  • Your rights regarding your health information.
  • Our responsibilities to protect your privacy.

Our Privacy Practices are shown below. If you would like to download our Privacy Practices, CLICK HERE.

Acknowledgment

By signing below, I acknowledge that:

  • I have received or been offered a copy of the provider’s Notice of Privacy Practices.
  • I understand that this notice explains how my health information may be used and disclosed.
  • I may revoke this acknowledgment in writing at any time.
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