🔒 HIPAA Acknowledgment & Privacy Notice

🔒 Your privacy is protected. This form is required by federal law (45 CFR §164.520). It acknowledges that you have received and reviewed our Notice of Privacy Practices.

📋 Section 1 — Client Information

🔒 Section 2 — Notice of Privacy Practices

How We Use Your Health Information Martinez Heart & Home Care collects and uses your personal health information only as necessary to provide and coordinate your care, comply with legal requirements, and communicate with your authorized representatives and healthcare providers. We will never sell your health information or use it for marketing purposes without your explicit written authorization.

Your Rights Under HIPAA You have the right to: (1) access and receive a copy of your health information; (2) request corrections; (3) request restrictions on use or disclosure; (4) receive a list of disclosures; (5) file a complaint if you believe your privacy rights have been violated.

Contact & Complaints Questions or complaints: 360.296.2671 or mariatmartinez1980@outlook.com. You may also file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights.

I acknowledge that I have received, read, and understand the Notice of Privacy Practices of Martinez Heart & Home Care. * I consent to the use and disclosure of my health information for treatment, payment, and healthcare operations as described in the Notice of Privacy Practices. * I understand I have the right to request restrictions on how my information is used or disclosed. I understand I have the right to access and receive a copy of my health information. I understand I may file a complaint if I believe my privacy rights have been violated.

👥 Section 3 — Authorized Representatives (Optional)

✍️ Section 4 — Signature

Signature * (draw below) Clear

Required by federal law (45 CFR §164.520). DSHS Form MHH-02.

✅ Submit HIPAA Form