By signing this form, I acknowledge that I have had the opportunity to review Newton-Wellesley Psychiatry’s (NWP’s) Notice of Privacy Practices which provides information about how NWP may use and disclose information about me for treatment, billing, and coordination of care.

I also understand that if NWP amends its Notice of Privacy Practices, the amended notice will be posted on our website and available for review in its office.

I have the right to request, in writing, that Newton-Wellesley Psychiatry (NWP) restricts how it uses information about me, but I realize that NWP is not required by law to grant my request. However, if NWP does decide to grant my request it must adhere to the approved restrictions unless it is an emergency situation or if such adherence would conflict with state or federal laws or regulations.