• Acknowledgement of Receipt of Notice

  • Miguel L. Gallegos, MD

    8004 Constitution Pl. N.E.

    Albuquerque, NM 87110

    (505) 924-2225

     

    I hereby acknowledge that I read a copy of this medical practice’s HIPPA Patient Rights.

  •  - -
  • Format: (000) 000-0000.
  • For office use Only:

     

    Signed form received by: ____________________________________________

    Acknowledgement refused:

                Efforts to obtain/ reasons for refusal:

                __________________________________________________________

                __________________________________________________________

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