ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

Please correct the errors described below.

Patient Name:

Address:

City:

State:

Zip:

I have received a copy of the Notice of Privacy Practices.

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 / Guardian

Date:

Patient Privacy Information

When notifying you for any reason, may we (Please check all that apply)

Leave a message on a home answering machine

Leave a message with spouse

Call you on your cell

Call you at your place of employment

Other

If other, please specify:

FOR OFFICE USE ONLY

We were unable to obtain a written acknowledgement of receipt of the Notice of Privacy Practices because:

An emergency existed and a signature was not possible at the time. The individual refuses to sign. A copy was mailed with a request for a signature by return mail. Unable to communicate with the patient Other

If unable to communicate with the patient, please state the reason:

If other, please specify:

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.

Prepared by

Signature

Date

Your information will be encrypted.

Electronic signature

Your browser does not support capabilities required for electronic signatures.

Loading templates...

Use existing signature
Type the signature
Draw
Upload an image

Click a signature you want to use:

Clear

Drop image file here or click to select file Click here to select image file from your computer

I request that my signature be represented by the above electronic signature and consent to recipients of electronic documents that I sign receiving personal information about me, including my email and IP addresses.

Use this signature or Cancel

Hushmail

Hide