Acknowledgement of Receipt of Notice of Privacy Practices
Please correct the errors described below.
Facility name - Bloomington Pediatrics
I have been given a copy of a Bloomington Pediatrics’ Notice of Privacy Practices which describes how my healthy information is used and shared. I understand that Bloomington Pediatrics has the right to change this Notice at any time. I may obtain a current copy by contacting the Facility Privacy Official or by visiting the web site at bloomingtonpediatrics.com
My signature below acknowledges that I have been provided with a copy of the Notice of Privacy Practices:
For facility use only
Complete this section if you are unable to obtain a signature.
Signature of Facility Representative
Your information will be encrypted.
Your browser does not support capabilities required for electronic signatures.