Acknowledgement of Receipt of Privacy Practices
I hereby acknowledge receipt of the physician's Notice of Privacy Practices. The Notice of Privacy Practices provides information about how the practice may use and disclose my confidential information. I am only acknowledging receipt of the policy.
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.
For the Foot and Ankle Center of Illinois, Ltd. to disclose private health information about you to parties not covered in our Notice of Privacy Practices, you will need to complete this section.
Your information will be encrypted.
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