HIPPA Acknowledgement

Acknowledgement of Receipt of Notice of Privacy Practices

**You may refuse to sign this notice**
I acknowledge that I have received a written copy of this office's Notice of Privacy Practices.
Patient's Name
Patient's Signature

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(Parent's signature if patient is a minor)
Date

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Authorization for Leaving Messages
I authorize Drs. Harnois and Kowalczyk's staff to leave a message on my home voice mail, answering machine or other electronic device, mobile phone or with a person who answers my home or mobile phone in regards to my appointment, pre medication, health, or my financial obligations to the practice.
Patient's Name
Patient's Signature

Clear
(Parent's signature if patient is a minor)
Date

MonthDayYear
Date
Should be Empty:

Acknowledgement of Receipt of Notice of Privacy Practices