HIPPA FORM

In order to comply with the Health Information Portability and Accessibility Act (HIPAA), effective April 14, 2003, your initial is required on this form. It will be kept in your patient record to indicate that you have read and/or received a copy of our notice of policies and practices to protect the privacy of your health information.

Click here to download, review, and print our Notice of Policies and Practices.

Doctor:*

John C. Burnside M.D.Kristeen R. Spratley M.D.William Lee M.D.

Patient's full name:*

First NameLast Name

By initialing below, I certify that I have received and reviewed a copy of the Notice of Policies and Practices.

Patient/guardian initials:*

Today's date:*

MonthDayYear

HIPAA Form