Acknowledgement of Receipt of Privacy Notice

Please correct the errors described below.

For Office Use Only:

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

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.

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

Your information will be encrypted.