innerQuest,pllc
932 Hendersonville Road, Suite 104
Asheville, North Carolina 28803
----------------------------(828) 333-5240
(828) 333-5423 Fax
.
.
Leonard Cruz, M.D.
Steven Buser, M.D.
NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT
I understand that, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), I
have certain rights to privacy regarding my protected health information. I understand that this
information can and will be used to:



Conduct, plan and direct my treatment and follow-up among the multiple healthcare
providers who may be involved in that treatment directly and indirectly.
Obtain payment from third-party providers.
Conduct normal healthcare operations such as quality assessment and physician
certifications.
I have received, read, and understand your Notice of Privacy Practices containing a more
complete description of the uses and disclosures of my health information. I understand that
this organization has the right to change its Notice of Privacy Practices from time to time and
that I may contact this organization at any time to address above to obtain a current copy of the
Notice of Private Practices.
I understand that I may request in writing that you restrict how my private information is used or
disclosed to carry out treatment, payment or health care operations. I also understand you are
not required to agree to my requested restrictions, but if you do agree then you are bound to
abide by such restrictions:
Patient Name:
Relationship to Patient:
Signature:
Date:
OFFICE USE ONLY
I attempted to obtain the patient’s signature in acknowledgement on this Notice of Privacy
Practices Acknowledgement, but was unable to do so as documented below:
Date:
Initials:
Reason:
innerQuest,pllc
932 Hendersonville Road
Suite 104
Asheville, North Carolina 28803
----------------------------(828) 333-5240
(828) 333-5423 Fax
.
.
. Steven Buser, M.D.
.
Leonard Cruz, M.D.
CONFIDENTIAL COMMUNICATIONS FORM
I hereby request that all communications from innerQuest,pllc be directed to the following:
Telephone:
Home:
________________________
Cellular: _______________________
Business:
________________________
Pager:
_______________________
Other:
You have my permission to leave messages:
On my home answering machine (please initial)
On my cell phone (please initial)
Yes _____
Yes _____
No _____
No _____
With the following people (please list name(s) and relationship)
Alternate Address for mailing letters and statements:
Street and/or P.O. Box:
City, State ZIP
This request will become effective as of the date indicated below. Any changes to this
information must be done so in writing by completion of another Confidential Communications
Form by the responsible party. By signing this, I am giving innerQuest,pllc permission to
contact me including leaving messages if necessary concerning confirmation of appointments
and to provide information about treatment issues at the above address and/or telephone
number(s) listed.
Signature
Date
Office Use Only
Date record updated in system:
Initials: