Acknowledgement of Privacy Practices

Patient First Name:
Last Name:
By typing your name below, you acknowledge it as an electronic signature.

E-Signature of Responsible Party:
Date E-signed:
Authorization for the following patient representatives to be given access to protected information and/or provide consent related to treatment or payment information.
1. Name:
Relationship:
2. Name:
Relationship:
3. Name:
Relationship:
4. Name:
Relationship:
5. Name:
Relationship:
6. Name:
Relationship:
List any legally prohibited people here:
We will use our professional judgement and experience with common practice in your best interest to allow picking up of medical supplies, x-rays, or other similar forms of health information

*You may refuse to sign this acknowledgement