PARC Surgical Center - Patient Acknowledgement of Disclosure

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Patient Name* This field is required.
First Name
Last Name
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Patient Birth Date* This field is required.
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Day
Year
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My signature below acknowledges the following:
As required by law I have received a copy and was informed verbally of the Patient Bill of Rights; and have had an opportunity to receive verbal assistance in understanding and exercising these rights.
I have received a copy/am aware of this office’s Notice of Privacy Practices, including the Private Health Information (PHI) designated at the time of visit.
I have received information on/am aware of the Infection Control measures utilized by this organization.
I have received a copy/am aware of the Practice Disclosure (about our Practice, including the Grievance process) and am comfortable with that information. I also understand this practices position on Do Not Resuscitate (DNR) and Living Wills and that this practice does not honor these directives.
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By signing this Acknowledgment of Disclosure, you acknowledge that you have read and understand the foregoing Notice to Patients regarding physician.

By signing this document, I also acknowledge that I have received a copy of the organization’s Notice of Privacy Practices. This acknowledgement is required by the Health Insurance Portability and Accountability Act (HIPAA) to ensure that I have been made aware of my privacy rights.
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Disclosure of Ownership

PARC Surgical Center is a physician owned facility and your physician may have a financial interest in the

center. You have the right to choose where you receive medical and surgical services including an entity in which your physician may have a financial relationship. You will not be treated differently by your physician if you choose to use a different facility. If desired, your physician can provide information about alternative providers. If you have any questions regarding this information, please feel free to ask your physician or any of our staff members. We welcome you as a patient and value our relationship with you.

For questions regarding this document, please contact the business office at:
PARC Surgical Center: 3716 Standridge Drive, Suite 100, The Colony, TX 75056 (469) 249-9000
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Name of Person Completing Form* This field is required.
First Name
Last Name
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Relationship to Patient
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Signature of Patient/Patient Guardian* This field is required.
Clear
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Today's Date
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