Notice of Privacy Practices Acknowledgement

Patient Name:

Date of Birth:

I acknowledge that Julie Tomberlin MD PA has made available to me a copy of the practice’s Notice of Privacy Practices, which is at the front desk.

I also acknowledge that I have been afforded the opportunity to read the Notice of Privacy Practices and ask questions.

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.

Patient Signature:

Date:

Personal Representative Signature (if applicable):

Relationship to Patient:

Your information will be encrypted.