Sunita Talwar, MD

Statement of Privacy Practices
 

This notice states our commitment to protecting the privacy of your medical records. A detailed policy of practices is available at the front desk upon request and describes fully how medical information about you may be used and disclosed and how you can get access to this information.

I have received the statement of Privacy Practices for the office of Dr. Sunita Talwar.

 

Print Name: _____________________________________________________

Signature__________________________________________Date__________

Please answer the following questions, so that we have your preferences listed in your file

 

1. May we leave messages with test results or other medical information on your answering machine/voice mail at home?

  Yes   No

2. May we leave message with test results or other medical information on your answering machine/voice mail at work?

  Yes   No

3. May we disclose your medical information to your spouse?

  Yes   No

4. May we disclose your medical information to your adult child?

  Yes   No