Acknowledgement of Receipt of Privacy Notice

For Office Use Only:

Patient Name

Account Number

Date of Request

By signing this form, you acknowledge that Margolin, Keinarth & Alberda, M.D. has given you a copy of its Privacy Notice, which explains how your health information is handled within this practice for various situations. We must try to have you sign this form on the first date of service with Margolin, Keinarth & Alberda, M.D. on or after April 14, 2003. This includes the situation where your first date of service occurred electronically.

If your first date of service with Margolin, Keinarth & Alberda, M.D. was due to an emergency, we must try to give you this notice and get your signature acknowledging receipt of this notice as soon as we can after the emergency

Check all that apply

I have received Margolin, Keinarth & Alberda, M.D.’s Privacy Notice.

Margolin, Keinarth & Alberda, M.D. has given me the chance to discuss my concerns and questions about the privacy of my health information.

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.

Patient Name

Margolin, Keinarth & Alberda, M.D. staff should complete if Acknowledgement Form is not signed:

1. Does patient have copy of the Privacy Notice?

Yes No

2. Please explain why the patient was unable to sign acknowledgement and staff efforts to obtain signature:

Your information will be encrypted.