Notice of First Latch & Counseling Inc. Privacy Practices
Effective March 21, 2019
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU OR YOUR CHILD MAY BE USED AND DISCLOSED AND HOW YOU GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires us to provide this Notice of Privacy Practices (NPP) to our patients and request acknowledgment of receipt. This Notice is published and available for review on our website; our patients acknowledge receipt of this notice when authorizing consent for treatment for themselves or their child(ren) from First Latch & Counseling Inc.
I grant permission to First Latch & Counseling Inc., its officers, directors, owners, principals, agents, volunteers, trainees and staff specifically including, without limitation, Jennifer Leopold, Tova G. Ovits, Chaya Deborah Stern and Stephanie Minnich (collectively “First Latch & Counseling, Inc.”) to share pertinent information about this consultation along with any and all future personal, phone, text and/or email communications with my/our family physicians and health care providers, the referring person, spouse or partner, my/our community breastfeeding helper and/or my/our insurance companies. I understand that I have a right to revoke this authorization by providing prior written notice to First Latch & Counseling, Inc. at 1827 E. 28thStreet, Brooklyn, NY 11229. However, this authorization may not be revoked if First Latch & Counseling, Inc. has taken action on this authorization prior to receiving my written notice. First Latch & Counseling Inc. reserves the right to change the privacy practices that are described in this notice. I may obtain a revised notice of privacy practices by writing or calling the First Latch& Counseling, Inc. at 917-750-9708 and requesting a revised copy be sent in the mail. Any complaint about an alleged breach of privacy must be submitted in writing to First Latch & Counseling, Inc. at the address provided above. I understand that I have a right to have a copy of this authorization and further understand that this authorization is voluntary and that I may refuse to sign this authorization. I understand that this consent shall remain in force from this time forward.