Acknowledgement of Receipt of Notice of Privacy Acts

Acknowledgement of Receipt of Notice of Privacy Acts
Purpose: This form is used to obtain acknowledgment of receipt of our Notice of Privacy Practices or to document our good faith effort to obtain acknowledgement.

YOU MAY REFUSE TO SIGN THIS ACKNOWLEDGEMENT
I, the parent/legal guardian of,
(child's/children's name(s)) *
have received a copy, or have had access to a copy of this office’s Notice of Privacy Practices.
Parent/Guardian Name: *
Date: *

Month Day Year
Date
Parent/Guardian Signature *

Clear
Authorization to Release Information to People other than Yourself

Purpose: This form is used to obtain authorization to release information regarding you and/or your child/children covered under the Privacy Act to people other than yourself. I, parent/legal guardian of the above named child/children, authorize the following person(s) to have access to information covered under the Privacy Practice regarding myself and/or child/children. (i.e. step-parent, nanny, grandparent, etc.)
Parent/Guardian Signature: *

Clear
Print Name & Relationship to Patient
Print Name & Relationship to Patient
Print Name & Relationship to Patient
Should be Empty: