Due to HIPAA (Health Insurance Portability and Accountability Act) regulations, we are required to obtain your written acknowledgment that you have had the opportunity to receive a copy of our Notices of Privacy Practices. You may obtain a paper copy at our office, or if you prefer you may obtain it electronically by clicking the link below called "Notices of Privacy Practices".
We ask that you sign the Acknowledgment and Consent form that shows you have received a copy. You may obtain a paper copy at our office, or if you prefer you may obtain it electronically by clicking the link below called "CONSENT".
You can mail this Acknowledgment and Consent to:
Salem Clinic Privacy Officer
2020 Capitol Street NE
Salem, Oregon 97303
or bring it to with you to your next appointment.
Download a PDF version of our CONSENT form. (PDF file. Requires the free Adobe Reader to view.)
Download a PDF version of our Notice of Privacy Practices. (PDF file. Requires the free Adobe Reader to view.)
