Pediatric Associates of Denham Springs

NOTICE OF PRIVACY PRACTICES

Our Notice of Privacy Practices ("Notice") provides information about:

The privacy rights of our patients; and
How we may use and disclose protected health information about our patients.

Federal regulations require that we give our patients or their authorized representatives our notice before signing this acknowledgement.

If you have any questions about your rights or our privacy practices, please send an electronic message (e-mail) to wzganjar@denhamspringspeds.com or a letter to:

Pediatric Associates of Denham Springs
c/o Privacy Officer
1213 North Range Avenue, Denham Springs, LA 70726

By signing this form, you are only acknowledging that you have been provided our notice.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Signature of Patient or Authorized Representative

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Print Name of Patient/Authorized Representative

PRACTICE USE ONLY

I have attempted to obtain the parent/guardians signature in acknowledgement of our Notice of Privacy Practice Acknowledgement, but was unable to do so as documented below.

Reason

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