Notice of Privacy Practices

Patient's Name

Address

City

State

Zip

I have received a copy of the Notice of Privacy Practices for the above named practice.

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.

Signature

Date

FOR OFFICE USE ONLY

We were unable to obtain a written acknowledgement of receipt of the Notice of Privacy Practices because

An emergency existed & a signature was not possible at the time.

The individual refused to sign.

A copy was mailed with a request for a signature by return mail.

Unable to communicate with the patient for the following reason:

Other

(Reason) Please Specify

If Other, Please specify

Prepared By

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Date

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