Kathy Levine MS, RD, CDN
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Privacy Forms (HIPAA)

    To submit privacy consent form digitally, fill out this form:

    Notice of privacy practices (HIPAA)

    I understand that your privacy is important.  Your information will only be used for billing or, with your permission, to communicate with other people (e.g. doctors or family members).

    Your right to privacy is protected by law under HIPAA, the Health Insurance Portability and Accountability Act of 1996.
Submit

To download and print HIPAA documents click on the links below:

Notice of privacy practices (HIPAA)

I understand that your privacy is important.  Your information will only be used for billing or, with your permission, to communicate with other people (e.g. doctors or family members).

Your right to privacy is protected by law under HIPAA, the Health Insurance Portability and Accountability Act of 1996. For more information, please refer to the HIPAA documents linked below.  
  • HIPAA Consent Form (Please bring filled out form to office or fill out digital version above)
  • Detailed Privacy Information

Goldens Bridge Office Building
​100 North County Shopping Center
Suite 203
PO Box 223
Goldens Bridge, NY 10526   

 Phone: (914) 767-0734
Fax: (914) 232-8537
rdklevine@gmail.com