pembrokeprimarycare.com - PPC HIPAA-ACKNOWLEDGEMENT OF RECEIPT

HIPAA-ACKNOWLEDGEMENT OF RECEIPT

HIPAA-ACKNOWLEDGEMENT OF RECEIPT
WE ARE REQUIRED TO PROVIED YOU WITH A COPY OF OUR NOTICE OF PRIVACY PRACTICES, WHICH STATES HOW WE MAY USE AND OR DISCLOSE YOUR HEALTH INFORMATION. PLEASE SIGN THIS FORM TO ACKNOWLEDGE RECEIPT OF THE NOTICE. ALSO PLEASE FILL OUT THE BOTTOM OF THE FORM WITH THE NAME/S OF THE PEOPLE YOU GIVE US PERMISSION TO RELEASE ANY HEALTH INFORMATION TO.
I ACKNOWLEDGE THAT I HAVE RECEIVED AND UNDERSTAND THE OFFICE'S NOTICE OF PRIVACY PRACTICES.
SIGNED:
DATE:

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I AUTHORIZE ANIKET CHAKRABARTI, M.D. P.C. AND STAFF TO RELEASE MY MEDICAL INFORMATION TO THE FOLLOWING:
NAME:
RELATIONSHIP:
NAME:
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NAME:
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