HIPAA NOTICE OF PRIVACY PRACTICES

I consent to the use or disclosure of my protected health information by Chokmah Development &
Consulting, Inc., for the purpose of providing me with healthcare treatment, getting paid for those
services and conducting the healthcare operation portion of its business. I also acknowledge that I
received and read the Chokmah Development & Consulting, Inc. notice of privacy practices.

I understand the following:

• My protected health information (HIPAA) means by health related information either collected
from me or received by the office from any other source, and it includes information about my
past, present and future physical or mental health.
• If I refuse to sign this Consent and Acknowledgment, the office has the right to refuse me as a
patient.
• I have the right to ask the Office, in writing, to limit the way in which it uses or discloses my
protected treatment information but Chokmah Development & Consulting, Inc. does not have
to agree to my request. However, if Chokmah Development & Consulting, Inc. does agree.
Then it is bound by that agreement.
• I have the right to revoke the consent portion of this document at any time by Chokmah
Development & Consulting, Inc. with a written request specifically stating my desire to revoke
my consent to Chokmah Development & Consulting, Inc. use of my PHI. Chokmah
Development & Consulting, Inc. must accept this revocation by me then may refuse to provide
me with further healthcare treatment.
• If I revoke the consent portion of this document, it is effective except to the extent that the office
has already used or disclosed my protected health information in reliance on this consent.

Before I signed this Consent and Acknowledgment, I received Chokmah Development & Consulting,
Inc. notice of privacy practices and understand the following with respect to the notice:
• Chokmah Development & Consulting, Inc. has the right to change the terms of the notice at
any time but if it does, it must post the new notice in the waiting room and give me a copy if I
request one.
• The notice describes in detail the types of uses and disclosure of my protected health information
that Chokmah Development & Consulting, Inc. may make in treating me, getting paid for that
treatment or in carrying out its healthcare operation.
• The notice also describes my rights with respect to my protected health information and
Chokmah Development & Consulting, Inc. obligations to protect the confidentiality of that
information.

I have read and understand this information and have received a copy of this Consent and
Acknowledgment. I am the patient, or I am authorized to act on behalf of the patient as his/her legal
guardian.

Parent/Guardian Printed Name Date

Parent/Guardian Signature

Child’s Name: Page 4 of 22

 HIPAA NOTICE OF PRIVACY PRACTICES

This notice describes how medical information about you may be used and disclosed by Chokmah
Development & Consulting, Inc. and how you can get access to this information. Please review it
carefully.

What is your medical information?

All the healthcare related information Chokmah Development & Consulting, Inc. has in your file,
including you medical history, current condition diagnosis treatment, plan of care, evaluation report,
progress notes and prescriptions.

Why are you getting this notice?

The office must comply with the HIPAA privacy rule that requires the office to protect the confidentiality of
your medical information. The Privacy Rule also gives you certain rights with respect to that information.
This notice explains both our obligations and your right under the Privacy Rules.

Patient/Guardian Rights:
Although your health record is Chokmah Development & Consulting, Inc. property, the information in
your file belongs to you. You have the right to:
• Request that the office restrict its use or disclosure of your medical information for treatment,
payment and healthcare operations. Please note that the office does not have to agree to the
requested restrictions, but if it does, the office must abide by the restrictions.
• Request that the office use an alternative means to communicate with you on a confidential basis
about your medical information. You may also request that we send such communication to you
at an alternative location.
• Inspect and copy your medical information for as long as the office maintains your medical
record. Under certain specific circumstances, the office may deny your request, but this denial, in
most cases, is reviewable. Please note that there is some medical information that you do not
have a right to access, including information prepared in anticipation for administrative
proceedings.
• Except for certain disclosures, requests and accounting of disclosures of your medical information
by the office.
• Receive a paper of copy of this Notice.

Child’s Name: Page 5 of 22

 HIPAA NOTICE OF PRIVACY PRACTICES

Chokmah Development & Consulting, Inc. Obligations

We are required to do the following:

• Maintain the privacy of your medical information and provide you with notice.
• Abide by the terms of this Notice and post it at the office where you can easily see it.
• Accommodate your reasonable request to communicate with you via alternative means or at an
alternative location.

Please note that the office reserves the right to its privacy practices and apply the changes to your
medical information. If we do change our privacy practices, we will mail you a revised notice to the
address you have provided to us.

Use and disclosures: There are some examples of the uses and disclosure of your medical
information that Chokmah Development & Consulting, Inc. will make: We will provide you with a copy
of your clinical records unless we cannot practicably do so, but you must make your request in writing to
us. We will charge you a reasonable cost-based fee for expenses such as copies and staff time. You
may also request access by sending us a letter to the address at the end of this Notice. If you request
copies, we will charge you $1.00 for each page, $15.00 per hour for staff time to locate your health
information and postage if you want copies mailed to you. If you request an alternative format, we will
charge a cost-based fee for providing your health information in that format. If you prefer, we will prepare
a summary or an explanation of her health information for a fee. Contact us using the information listed
at the end of this Notice for a full explanation of our fee structure.

Restriction: You have the right to request that we place additional restrictions on our use or disclosure
of your health information. We are not required to agree to these additional restrictions, but if we do, we
will abide by our agreement (except for an emergency).

I HAVE RECEIVED, READ AND UNDERSTOOD MY HIPAA NOTICE OF PRIVACY PRACTICES FROM
CHOKMAH DEVELOPMENT & CONSULTING, INC.

Parent/Guardian Printed Name Date

Parent/Guardian Signature

Child’s Name: Page 6 of 22

 HIPAA NOTICE OF PRIVACY PRACTICES

Questions and Complaints

If you want more information about our privacy practices or if you have any questions or concerns;
please contact us. If you are concerned that we may have violated your privacy rights, or you disagree
with a decision we have made about access to your health information or in response to a request you
made to amend or restrict the use of your health information or to have us communicate with you by
alternative means or at alternative locations, you may complain to us using the contact information listed
at the end of this Notice. You may also submit a written complaint to the U.S. Department of Health and
Human Services. We will provide you with the address to file your complaint with the U.S. Department
of Health and Human Services upon request.

We support the right to the privacy of your health information. We will not retaliate in any way if you
choose to file a complaint with us or with the U.S. Department of Health and Human Services.

Contact Officer: Dorinda Luzardo

Telephone: (305) 828-5276
Fax: (786) 369-0926
Address: 1486 W 84th Street, Hialeah, FL 33014

PLEASE KEEP THIS PORTION FOR YOUR RECORDS

Child’s Name: Page 7 of 22

 Chokmah Development & Consulting, Inc.
1486 W 84th Street, Hialeah, FL 33014

RETURN THIS PORTION OF THE PACKET

I have received, read, and understand this HIPAA Notice of Privacy Practices. I have received and
understand the Service Participant Handbook detailing all policies, procedures, rights, responsibilities,
admission, discharge, transition, and referral procedures.

Parent/Guardian Printed Name Date

Parent/Guardian Signature

Child’s Name: Page 8 of 22