waterburychiropracticwellness.com - Acknowledgement Form

NOTICE OF PRIVACY PRACTICE SUMMARY - ACKNOWLEDGEMENT
The Health Insurance Portability and Accountability Act (HIPAA) require us to give you a notice of our privacy practices and to acknowledge your receipt of this notice.

What is the NOTICE OF PRIVACY ACT PRACTICES?

The NOTICE OF PRIVACY PRACTIES explains how your health information may be used and or disclosed by us. In addition, it explains your rights with regard to your protected health information, as well as our legal responsibilities
I have been provided with a copy of the Notice of Privacy Practices Summary:

May we share your medical information with others listed below to appropriately care for you?

May we leave DETAILED medical information on voice mail?

	Yes	No
Home Voice
Cell Voice

May we leave a text message which may contain DETAILED information on your cell phone?

YesNo
Patient Name:
Email:
example@example.com
Patient Date of Birth:

MonthDayYear
Date
Home Phone:
Please enter a valid phone number.
Cell Phone:
Please enter a valid phone number.
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Patient Signature:

Clear
Date:

MonthDayYear
Date
Should be Empty:

NOTICE OF PRIVACY PRACTICE SUMMARY - ACKNOWLEDGEMENT