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2020 J Street, Sacramento, CA 95811 Phone 916.341.0575 Fax 916.341.0122 www.snahc.orgAuthorization to Release Records This request concerns health information regarding: Patient Name: ___Date of Birth:
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The 'Notice of Privacy Practices' outlines how health information about individuals may be used and disclosed, as well as individuals' rights regarding their health information.
Healthcare providers, health plans, and healthcare clearinghouses that handle protected health information are required to file this document.
To fill out the Notice of Privacy Practices, entities must include details about how they use patient information, patient rights, and how patients can file complaints or get more information.
The purpose is to inform patients about their privacy rights and how their health information will be protected and used.
The report must include types of health information collected, how it is used and disclosed, patient rights, and the contact information of a designated privacy officer.
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