Notice of Privacy Practice Form

Please correct the errors described below.

By signing this form, you acknowledge receipt of the Panda Pediatrics and Adolescent Care Notice of Privacy Practices. Our notice of Privacy Practices provides information about how we encourage you may use and disclose your protected health information. We encourage you to read it thoroughly.

Our Notice of Privacy Practices is subject to change. If we change our Notice, you may obtain a current copy of the revised Notice by contacting

Practice Administrator

515 W Buckeye Rd, Suite 105, Phoenix AZ 85003 (602) 283-3165

If you have any questions concerning the Notice, or if you believe that your privacy rights have been violated, you should call the matter to our attention by sending a letter describing the cause of your concern to the above-mentioned official and address. You will not be penalized or otherwise retaliated against for filing a complaint. I acknowledge that Panda Pediatrics and Adolescent Care has provided me with the opportunity to review their Notice of Privacy Practices.

Español

Firmando esta forma, usted reconose recibir el Aviso de Practicas Privadas de PANDA PEDIATRICS AND ADOLESCENT CARE. Nuestro aviso de praticas privadas proeve informacion aserca de como nosotros podemos usar y revelar su informacion medica protejida. Recomendamos que ested lo lea en detalle. Nuerto Aviso de Praticas Privadas es subjeto a cambier. Si cambiamos nuestro Aviso, usted obtendra una nueva copia ya revisada pidiendolo al:

Administrator de la Practica

515 W Buckeye Rd, Suite 105, Phoenix, Arizona 85003 (602) 283-3165

Si usted tiene preguntas con referencia de nuestro aviso, o si usted cree que sus derechos de privacidad an sido violados, usted debe de traer el asunto

DISCLAIMER: 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. DESCARGO DE RESPONSABILIDAD: Al escribir su nombre a continuación, está firmando esta solicitud de manera electrónica. Usted acepta que su firma electrónica es el equivalente legal de su firma manual en esta solicitud.

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