Acknowledgement of Receipt of Notice of Privacy Practices

The Health Insurance Portability and Accountability Act (HIPAA) requires us to give you a notice of our privacy practices and to acknowledge your receipt of the notice.

The Notice of Privacy Practices explains how your health information may be used and or disclosed by us. In addition, it explains your rights with regard to your protected health information, as well as our legal responsibilities. You can view the Privacy Practices in one of three manners: we can email you a copy, you can view it on our website, or you may request a paper copy.

I have been provided with a copy of the Notice of Privacy Practices in electronic or paper format.

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.

Signature of Parent or Guardian

Date

Patient Name

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Please list the names of others with whom you would like to give permission to share your healthcare information (these may include family members or other individuals/entities):

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Your information will be encrypted.