1930 State Hwy 35

(732) 974-9100

Hippa Privacy Notice

HIPAA PRIVACY NOTICE

I.Acknowledgement of Practice's Notice of HIPAA Privacy

_____________________________________________________________

Name of PatientDate of Birth

_____________________________________________________________

Signature of Patient/Parent/GuardianDate

II.Designation of Certain Relatives, Close Friends, Care Givers

A.I agree that the practice may disclose certain of my health information to a family member, close personal friend, or other caregiver, since such a person is involved with my health care or payment relating to my health care. In that case, the Physical Practice will disclose only information that is directly relevant to the person's involvement with my health care or payment relating to my health care. I wish to be contacted in the following manner(s):

Home Phone: _____________________________

Check:o Ok to leave message with detailed information

o Leave call back numbers only

Work Phone: _____________________________

Check:o Ok to leave message with detailed information

o Leave call back numbers only

Cell Phone: _____________________________

Check:o Ok to leave message with detailed information

o Leave call back numbers only

Written Communication:

Check:o Ok to mail my home address

o Not ok to mail my home address

B.I designate the following persons listed below as persons involved with my health care or payment relating to my health care for the purpose of the practice making the limited disclosures described above. I understand that I am not required to list anyone. I also understand that I may change this list at any time in writing.

Print Name: ____________________________________________________________

Print Name: ____________________________________________________________

Print Name: ____________________________________________________________

CONTACT US TODAY

We look forward to hearing from you

Office Hours

Our Regular Schedule

Monday:

8:45-12:00

3:00-7:00

Tuesday:

8:45-12:00

Closed

Wednesday:

8:45-12:00

3:00-7:00

Thursday:

Appointment

Only

Friday:

8:45-12:00

3:00-6:15

Saturday:

8:30-11:30

Closed

Sunday:

Closed

Closed

Locations

Find us on the map

Testimonials

Reviews By Our Satisfied Patients

  • "Dr. Forzani and her staff are the best! They never make me feel rushed and provide great service and care."
    Justine H.
  • "I just recently started to see Dr. Forzani for a aggravated Sciatica. I absolutely adore her! She and her staff make you feel right at home! Dr. Forzani is very personable and listens! I would suggest this practice to my family and friends!"
    Sue B.

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