Please Fill Out The Form


Acknowledgment of Receipt

The Health Insurance Portability and Accountability Act (HIPPA) is a federal regulation designed to
ensure that you are aware of your privacy rights and of how your medical information can be used by
our staff in providing and arranging your medical care. Family Care USA, PLLC is furnishing you
with attached notice, which provides information about how Family Care USA, PLLC and its physician
may use and/or disclose protected health information about you for treatment payment, healthcare
operations and as otherwise allowed by law. By signing this form, you acknowledge that you have
received a copy of Family Care USA, PLLC notice of
Health Information Practices.


Approved HIPPA Contacts

Keeping our patient's information private is important to us and by default we will only disclose
information related to the patient's Billing Account, Medical Conditions to the patient or legal
guardian. If you would like to add additional contacts (other than the patient of legal guardian)
that Family Care USA, PLLC is allowed to disclose this type of information to, please complete the
fields below.