HIPAA Policy 5-11

HIPAA Acknowledgement of Notice of Privacy Practices
Alzein Pediatric Associates is required by law to maintain the privacy of and provide patients and their guardians with access to the Notice of our legal duties and privacy practices with respect to protected health information.
Name of Patient:*

First NameMILast Name
Patient's DOB:*

MonthDayYear
Date
I hereby acknowledge that I have reviewed the Hipaa Notice of Privacy document and understand that I may obtain a copy for my records upon request.
Signature of Patient/Legal Representative:*
Relationship to Patient:*
Today's Date*

MonthDayYear
E-mail Address of Patient/Legal Representative:*
example@example.com
Cell Phone of Patient/Legal Representative:*

Area CodePhone Number
Home Phone of Patient/Legal Representative:*

Area CodePhone Number
Please let us know which number you would like us to call regarding your medical information. We will leave a message at this number if we do not reach you.*

Home PhoneCell Phone
Should be Empty: