ROCK Notice of Privacy Practices Acknowledgement

I have been given the opportunity to review the ROCK, Ride On Center "Notice of Privacy Practices". This document contains a description of the uses and disclosures of my healthcare and my rights regarding such information. ROCK, Ride On Center displays the "Notice of Privacy Practices" in the Welcome Center. 

I understand that ROCK, Ride On Center has the right to change its "Notice of Privacy Practices" and that if changes are made, a revised copy of the notice will be posted in the Welcome Center. I also understand that if I have any questions or wish to receive copies or a current copy of the "Notice of Privacy Practices," I may contact:

Nancy Krenek and/or Shannon Middleton
2050 Rockride Lane
Georgetown, TX 78626
Telephone: (512) 930-7625   Fax: (512) 863-9231

By signing this form, I am acknowledging I have read the "Notice of Privacy Practices" and agree to the uses and disclosure information as described. I understand that refusing to sign this form does not stop disclosure of health information that has occurred prior to revocation or that is otherwise permitted by law without my specific authorization or permission. I understand that information disclosed pursuant to this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal or state privacy laws. 

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