CTTS - HIPAA- ACKNOWLEDGEMENT OF RECEIPT

HIPAA - Acknowledgement of Receipt

Notice of Privacy Practices
The Notice of Privacy Practices describes how health information about your child may be used and disclosed. A copy of this document is available for review at our clinic and may also be emailed by request. Please review it carefully as the privacy of your child’s health information is important to us.
Patient's Name*

First NameLast Name
I, Printed name of Patient or Parent / Legal Guardian* acknowledge that I have either received a copy of this office’s NOTICE OF PRIVACY PRACTICES or that this office’s NOTICE OF PRIVACY PRACTICES was made available to me to receive.
I, Printed name of Patient or Parent / Legal Guardian* consent to the use and disclosure of my personal health information by your office for Treatment, Billing / Payment and Health Care Operations as outlined in the NOTICE OF PRIVACY PRACTICES.
Signature of Patient or Parent / Legal Guardian*

Clear
Date Signed*

MonthDayYear
Date
Name of Responsible Party*

First NameLast Name
Should be Empty: