Acknowledgement of Receipt of Notice of Privacy Practices

have read and understand this office’s Notice of Privacy Practices.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

NOTICE: If there are any individuals that we are authorized to share your health information with please list below and their affiliation to you.

FOR OFFICE USE ONLY: We attempted to obtain written acknowledgment of receipt of our Notice of Privacy Practices, but acknowledgment could not be obtained because: