Dr. Gabriela Walsman Leiva 

8541 S Redwood Rd Ste B1, 

West Jordan, UT 84088 (801) 706-0171

This notice describes how health information about you (as a patient of this practice) may be used and disclosed, and how you can gain access to your individually identifiable health information.

A. OUR COMMITMENT TO YOUR PRIVACY:

Dr. Gabriela Walsman Leiva is dedicated to maintaining the privacy of your personally identifiable, protected health information (PHI). In conducting our business, we will create records regarding you and the treatment and services we provide to you. We strive to maintain the confidentiality of health information that identifies you. This notice explains the privacy practices that we maintain concerning your PHI.

The terms of this notice apply to all records containing your PHI that are created or retained by the Practice. We reserve the right to revise or amend this Notice of Privacy Practices. Any revision or amendment to this notice will be effective for all of your records that our Practice has created or maintained in the past, and for any of your records that we may create or maintain in the future. You may request a copy of our most current notice at any time.

IF YOU HAVE QUESTIONS ABOUT THIS NOTICE, PLEASE CONTACT:

Dr. Gabriela Walsman Leiva 

8541 S Redwood Rd Ste B1, 

West Jordan, UT 84088

B. WE MAY USE AND DISCLOSE YOUR PHI IN THE FOLLOWING WAYS: (This section remains the same as in the original document, covering Treatment, Payment, Health Care Operations, Appointment Reminders, Release to Family/Friends, and Disclosures Required by Law.)

C. USE AND DISCLOSURE OF YOUR PHI IN CERTAIN SPECIAL CIRCUMSTANCES: (This section remains the same, covering Health Oversight, Lawsuits, Law Enforcement, Deceased Patients, Organ Donation, Serious Threats, Military, and Workers’ Compensation.)

D. YOUR RIGHTS REGARDING YOUR PHI: (This section remains the same, covering Confidential Communications, Requesting Restrictions, Inspection and Copies, Amendment, Paper Copy of this Notice, Filing a Complaint, and Authorization for Other Uses.)

Acknowledgement

I hereby acknowledge that I have received and read this Notice of Privacy. I understand that I may request additional copies of this notice at any time.

Patient Name: _________________________ Date: ___________

* A full disclosure of Privacy Practices for Dr. Gabriela Walsman Medical Practice is available in her professional website: www.gratefulmd.com