Aviva Health Patient and Family Advisory Council Application
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Applicant's Name:
Services Used (check all that apply):
I understand that Umpqua Community Health Center dba Aviva Health (Aviva Health) has a legal and ethical responsibility to maintain patient privacy, including obligations to protect the confidentiality of patient information and to safeguard the privacy of patient information, including but not limited to patient medical records and other individually identifiable health information (collectively referenced herein as "Patient Information"). In addition, I understand that during the course of my visit at Aviva Health, I may see or hear other confidential information such as financial data and/or operational information pertaining to the organization that Aviva Health is obligated to maintain as confidential (collectively referenced herein as "Confidential Information"). As a condition of my visit or affiliation with Aviva Health, I understand that I must sign and comply with this agreement. By signing this document, I understand and agree that (you must check every box):
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