Withings Medical Group
HIPAA Acknowledgment of Receipt
Withings Medical Group's Notice of Privacy Practices describes how we may use and disclose your protected health information, and the rights you have regarding that information. The full Notice is available here: Notice of Privacy Practices. Please review it before you enroll.
What you acknowledge
By checking the box for this document during enrollment, you acknowledge that the Notice of Privacy Practices ("Notice") of Withings Medical Group ("Provider") has been made available to you and that you have been given an opportunity to review it, and you confirm that you understand the following:
- I have certain rights to privacy regarding my protected health information.
- The Provider can and will use my health information for purposes of my treatment, payment for treatment, and health care operations.
- The Notice explains in more detail how the Provider may use and share my protected health information for other purposes.
- I have the rights regarding my protected health information that are described in the Notice.
- The Provider may change the Notice from time to time, and I may obtain a current copy of the Notice by contacting the Privacy Officer identified in the Notice or at Privacy@Withings.com.
How this document is agreed to
This document is provided and agreed to electronically as part of enrollment in the ACCESS program of Withings Medical Group. There is no handwritten signature. You indicate your acknowledgment by checking the box for this document and typing your full name on the consent step of enrollment.
Withings Medical Group keeps a record of your typed name, the date and time of your agreement, and the version of this document that was shown to you. Under the federal Electronic Signatures in Global and National Commerce Act (ESIGN Act) and applicable state Uniform Electronic Transactions Act (UETA) laws, this electronic agreement is as valid as a handwritten signature.
If you are completing enrollment on behalf of the patient, you confirm that you are the patient's legal guardian, health care agent, or other personal representative authorized under applicable law to act for the patient, and that you are agreeing in that capacity.
You may request a paper copy of this document, or ask questions about it, at any time by calling (888) 854-7196 or writing to Privacy@withings.com. You may obtain a current copy of the Notice at any time from the Privacy Officer identified in the Notice.