• 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.

  • I would like to receive a copy of any amended Notice of Privacy Practices by sending a request to Stacy Taylor, Privacy Officer, at the above address and phone number.
  • Date:
     - -
  • Format: (000) 000-0000.
  • If not signed by the patient, please indicate relationship to patient.

  • For office use Only:

     

    Signed form received by: ____________________________________________

    Acknowledgement refused:

                Efforts to obtain/ reasons for refusal:

                __________________________________________________________

                __________________________________________________________

  • Should be Empty: