Notice of Privacy Practices


Notice of Privacy Practices

  • Click to View our Privacy Practices Notice

  • Acknowledgement of Receipt of “Notice of Privacy Practices"

    I acknowledge that I have received a copy or view the online copy of the Notice of Privacy Practices issued by Jose A. Gaudier, MD, PA. This notice describes how Jose A. Gaudier, MD, PA. may use and disclose my protected health information, certain restrictions on the use and disclosure of my healthcare information, and rights I may have regarding my protected health information.
  • By signing this acknowledgment, I agree that Jose A. Gaudier, MD, PA. may use and disclose my protected health information as described. This acknowledgment and authorization will remain in effect indefinitely unless it is revoked in writing by me except to the extent that Jose A. Gaudier, MD, PA. may have already used or disclosed the information. However, I also understand that by revoking this authorization that I might be jeopardizing the service that Jose A. Gaudier, MD, PA. will be able to provide to me.