PRIVACY PRACTICES ACKNOWLEDGEMENT

I acknowledge that I have received the Notice of Privacy Practices and I have been provided an opportunity to review it.

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 of Patient or Patient’s Representative:

Date:

Birthdate:

Relationship to Patient:

If written acknowledgement is not obtained, please check reason:

Notice of Privacy Practices Given – Patient Unable to Sign Notice of Privacy Practices Given – Patient Declined to Sign Other

If Other, please specify:

Your information will be encrypted.