Notice of Privacy Practices Acknowledgment of Receipt

By signing this form, you acknowledge receipt of the Notice of Privacy Practices of Tomball Healthcare for Pediatrics. P.A. Our Notice of Privacy Practices provides information about how we may use and disclose your protected health information. We encourage you to read it in full.

Our Notice of Privacy Practices is subject to change. If we change our notice, you may obtain a copy of the revised notice by contacting us at (281) 351-6881.

If you have any questions about our Notice of Privacy Practices, please contact:
Kathy Pendland, Office Manager
(281) 351-6881.

I acknowledge receipt of the Notice of Privacy Practices of Tomball Healthcare for Pediatrics. P.A.

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.