Acknowledgment of Receipt of Notice of Privacy Practices

Your name and signature on this form indicates that you have been given the opportunity to review and request a copy of the Cepero Pediatrics, P.A. Notice of Privacy Practices(Notice) on the date indicated. If you have any questions regarding the information in the Notice, please do not hesitate to contact an office representative.

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

Patient Name:

Date of Birth

If Patient Representative, Name:

If Patient Representative, Relationship to Patient:

Date Noticed Received:

Patient or Representative Signature:

Your information will be encrypted.