I understand that, under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. I understand that if I choose to receive services for substance use disorder treatment at Spectra Health, that these records have additional privacy protections covered by 42 CFR part 2 regulations (Part 2) I understand that this information can and will be used to:

• Conduct, plan and direct my treatment and follow-up among my health care providers who may be involved in that treatment directly or indirectly.
• Obtain payment from third-party payers.
• Conduct normal health care operations such as quality assessments and practitioner certifications. 

HIPAA and Part 2 Covered Services

I acknowledge that I have received, read, and understand Spectra Health's Notice of Privacy Practices document describing the uses and disclosures of my health information as it relates to HIPAA and Part 2 protections for substance use disorder patient records (when applicable) I understand that I may ask questions about the information contained in this notice at any time, and that I may contact Spectra Health at any time to request a current copy of the Notice of Privacy Practices document.

Patient Rights and Responsibilities

I acknowledge that I have received Spectra Health's Patient Rights and Responsibilities, and Zero Tolerance Statement document describing the general expectations for receiving services at Spectra Health. I understand that I may ask questions about the information contained in this notice at any time, and that I may contact Spectra Health to request a current copy of the Patient Rights and Responsibilities, and Zero Tolerance Statement document.