Common use of Questions or Complaints Clause in Contracts

Questions or Complaints. If you have questions about this notice or think that we have not protected your private health information and you wish to complain about it, please contact: ▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇, Ph.D. at (▇▇▇) ▇▇▇-▇▇▇▇. You can also complain to the Federal Government by writing to the: Office for Civil Rights U.S. Department of Health and Human Services ▇▇▇ ▇▇▇▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇, ▇.▇. Room 509F, HHH Building Washington, D.C. 20201-0004 Or by calling the Office for Civil Rights at (▇▇▇) ▇▇▇-▇▇▇▇ By signing this form, you are acknowledging that you have received a copy of this notice (NOTICE OF USE OF PRIVATE HEALTH INFORMATION) Patient Signature Date Parent/Guardian Signature (if necessary) Date Thank you for choosing Pacific Pain and Wellness Group for your medical care. Our goal is to provide you with the highest quality of medical care and service. We feel it is helpful and important that you understand our billing process. We are happy to ▇▇▇▇ your insurance for any services provided at our offices. However, this is a courtesy service to you and you are responsible for any costs incurred during your course of treatment. Each patient must complete the Patient Information Record which includes all demographic information including your insurance. We must have this information completed before you see the doctor on your first visit.

Questions or Complaints. If you have questions about this notice or think that we have not protected your private health information and you wish to complain about it, please contact: ▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇, Ph.D. at (▇▇▇) ▇▇▇-▇▇▇▇. You can also complain to the Federal Government by writing to the: Office for Civil Rights U.S. Department of Health and Human Services ▇▇▇ ▇▇▇▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇, ▇.▇. Room 509F, HHH Building Washington, D.C. 20201▇▇▇▇▇-0004 ▇▇▇▇ Or by calling the Office for Civil Rights at (▇▇▇) ▇▇▇-▇▇▇▇ By signing this form, you are acknowledging that you have received a copy of this notice (NOTICE OF USE OF PRIVATE HEALTH INFORMATION) Patient Signature Date Parent/Guardian Signature (if necessary) Date Thank you for choosing Pacific Pain and Wellness Group for your medical care. Our goal is to provide you with the highest quality of medical care and service. We feel it is helpful and important that you understand our billing process. We are happy to ▇▇▇▇ your insurance for any services provided at our offices. However, this is a courtesy service to you and you are responsible for any costs incurred during your course of treatment. Each patient must complete the Patient Information Record which includes all demographic information including your insurance. We must have this information completed before you see the doctor on your first visit.