Acknowledgement of Receipt of Notice of Privacy Practices

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 Office Use Only

We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because:

HIPPA PRIVACY FORM

Acknowledgement of Receipt of Notice of Privacy Practices

This form is used to obtain acknowledgement of our notice of Privacy Practices or to document our good faith to obtain that acknowledgement.

Notice of privacy Practices, presents the information that federal law requires us to give our patients regarding our privacy practices. We must provide this Notice to each patient beginning no later than the date of our first service delivery to the patient after April 14, 2003. We must make good-faith attempt to obtain written acknowledgement of receipt of the Notice from the patient. We must also have the Notice available at the office for patients to request to take with them. We must post the Notice in our office in a clear and prominent location where it is reasonable to expect any patients seeking service from us to be able to read the notice. Whenever the Notice is revised, we must make the Notice available upon request on or after the effective date of the revision in a manner consistent with the above instructions. Therefore, we must distribute the Notice to each new patient at the time of service and to any person requesting a Notice. We must also post the revised Notice in our office as discussed above.