SECTION A: The Patient.
SECTION B: Acknowledgement of Receipt of Privacy Practices Notice.
I, name acknowledge that I have received a Notice of Privacy Practices from the above-named practice.
If a personal representative signs this authorization on behalf of the individual, complete the following:
SECTION C: Good Faith Effort to Obtain Acknowledgement of Receipt.
I attest that the above information is correct.
Include this acknowledgement of receipt in the individual's records.