HIPAA NOTICE OF PRIVACY & PRACTICES
We are required by law to maintain the privacy of and provide individuals with this notice of our
legal duties and privacy practices with respect to protected health information. If you have any
objections to this notice, please ask to speak with our HIPAA Compliance Officer in person or by
phone at our main phone number.
STANDARD AUTHORIZATION OF USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION
Information regarding my medical condition may be disclosed to:
Name Relationship Phone Number
Expiration Date of Authorization
Right to Terminate or Revoke Authorization
You may revoke or terminate this authorization by submitting a written revocation to Dr. Jamie Gottlieb.
Permission to Leave Message
Authorization for information regarding patient to be left by message to person or machine at designated phone number.
Dr. Jamie Gottlieb is part owner of the Unity Surgery Center in Mishawaka, Indiana. Dr. Gottlieb believes that any and all of their subsidiaries are appropriate settings for your medical care and services for which you are being referred. You may choose to be referred to an alternative health care facility for treatment.