Practices Written Acknowledgement Form
understand that as part of my healthcare, this facility originates and maintains health records describing my health history, symptoms, examination and test results, diagnosis, treatment and any plans for future care or treatment. I acknowledge that I have been provided with and understand that this facility’s Notice of Privacy Practices provides a complete description of the uses and disclosures of my health information. I understand that:
We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but it could not be obtained because:
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.
Your information will be encrypted.