ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

We want to thank you for taking the time to review our notice.

I have been informed of and given the opportunity to review and secure a copy of this office’s Notice of Privacy Practices.

I (parent/guardian or adult patient):
Patient First Name:
Patient Last Name:
Signature of Patient or Parent/Guardian:
Date:
I agree that you may disclose healthcare information to the following family, friends or caregivers, medical doctors and insurance company. Please list these below:
Name:
Relationship:
Name:
Relationship:
Name:
Relationship:
Name:
Relationship: