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

My signature below acknowledges that I have been provided with a copy of the Notice of Privacy Practices:

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Signature of Facility Representative

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