HIPAA Policy Acknowledgment (Bloomington)

HIPAA Policy Acknowledgment (Bloomington)

You'll find our HIPAA Privacy Notice in our Patient Policy Packet here: new-patient-info/bloomington-forms/. Please review it and download a copy for your records.
I, First Name* Last Name* , acknowledge that I have read and/or downloaded a copy of the Centerstone Health Services Incorporated Notice of Privacy Practices.
Please write your signature in the space below with your finger or mouse. *

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Witnessed by (sign) _____________________________________ Date________________
Failure to Obtain Signature

Date _________________________ Centerstone Health Services Incorporated presented this Acknowledgment to_______________________________. The patient refused to provide a signature. ________________________________________ Centerstone Heath Services, Inc signature
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