Notice of Privacy Practices

FAMILY SERVICE ROCHESTER- NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW MUCH MEDICAL INFORMATION ABOUT YOU MAY BE USED AND SHARED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

By filling out the following NOTICE OF PRIVACY PRACTICES form, I am acknowledging that I have been informed of the risks, including but not limited to my confidentiality in services, of transmitting my protected health information by unsecured means. I understand that I am not required to sign this agreement in order to receive requested services. I also understand that I may terminate this consent at any time.