Professional Documents
Culture Documents
In 1996, the Federal Government established uniform privacy and security standards to protect
patients' medical information. The standard is known as the Heaith Insurance Portability and
Accountability Act (HIPAA). The deadline for compliance is April 14, 2003.
The purpose of this notice is to ensure that you (the health-care recipient) or your designated
representatives are aware of your rights to ensure the privacy of your healthcare information.
Milestone Pediatric Therapy Services retains the right to update this notice at anytime. To obtain
the most recent notice, please summit a request in writing to the Privacy Officer of Milestone
Pediatric Therapy Services.
In addition to the above entities, Milestone Pediatric Therapy Services may communicate
with the following persons on my behalf for treatment and my health conditions: for
example: Treating Physicians, Therapists, Billing Service Provider, School System.
Please note this is a summary regarding our privacy policies. If you would like a detail
policy, please contact Milestone Therapy Services in writing or by telephone.
I hereby certify that I have received a copy of the Milestone Pediatric Therapy
Services Notice of Privacy Practices with an effective date of January 1, 2008. I
am aware and acknowledge that this Notice describes how my health information
may be used or disclosed. I understand that I should read it carefully. I am aware
that I may direct any questions, concerns, or complaints about the privacy
practices of Milestone Pediatric Therapy Services to the company’s Chief Privacy
Officer at (678) 863-2074.
I am also aware that my home health treatment requires that a copy of my clinical
record, containing protected health information, be kept in my home. I have been
advised and agree that the protection and security of my in-home clinical record
remains my responsibility; and I must be diligent to prevent persons not entitled or
authorized to view this information from accessing it.
______________________________ ___________________________
Signature(Parent/Legal Guardian) Relationship to Patient
______________________________ ____________________________
Printed Name Date
______________________________
Witness