Privacy Notice
Patient Name
*
First Name
Last Name
Email
*
example@example.com
ACKNOWLEDGMENT OF RECEIPT OF PRIVACY NOTICE
This Privacy Notice is being provided to you as a requirement of a federal law, the Health Insurance Portability and Accountability Act (HIPAA)
I acknowledge that I have received the attached Privacy Notice
*
Draw Signature
Upload Signature
I acknowledge that I have received the attached Privacy Notice
*
Patient or Personal Representative Signature
I acknowledge that I have received the attached Privacy Notice
*
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Patient or Personal Representative Signature
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of
If Personal Representative’s signature appears above, please describe Personal Representative’s relationship to the patient:
*
Type N/A if not applicable
Date
*
-
Day
-
Month
Year
Please answer the following questions to help us protect your privacy:
1) May we leave a detailed message on your answering machine?
*
Yes
No
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Contact Number
*
2) May we leave a message at your place of employment?
*
Yes
No
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Contact Number
*
Please let us know how you wish to be notified by our office.
*
3) May we release information to anyone other than you? (i.e. spouse, child, friend, etc)
*
Yes
No
Name
*
Name
Relationship
Name
Name
Relationship
WE WILL NOT RELEASE INFORMATION TO ANYONE NOT LISTED ABOVE
SUBMIT
Should be Empty: