ACKNOWLEDGEMENT OF RECEIPT OF NOTICE
As required by the Privacy Regulations, I hereby acknowledge that I have received a current copy of this practice’s “NOTICE OF PRIVACY PRACTICES.”
As required by the Privacy Regulations, Signature Specialists has explained the “NOTICE OF PRIVACY PRACTICES” to my satisfaction.
As required by the Privacy Regulations, I am aware that this practice has included a provision that it reserves the right to change the terms of its notice and to make the new notice provisions effective for all protected health information that it maintains.
I understand that this office is not required to honor any changes to the “Notice of Privacy Practices.” For example: If the patient changes the context of the Privacy Practices, such as changing how the referring doctor obtains the results of treatment ie: certified mail only, the practice is not required to honor that specific request.