Acknowledgement of Practice Procedures Form

Please correct the errors described below.

My Signature/initials below certify that I acknowledge, understand and assume all responsibility for this office's policies in accordance with insurance, appointments, payment and HIPAA Privacy Act.

I acknowledge that my signature below indicates my understanding and cooperation with the above statements. All questions and concerns have been answered to my satisfaction.

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.

A copy of this form will be provided upon your request.

Your information will be encrypted.