HIPPA

Acknowledgement of Receipt of HIPPA Notice of Privacy Practices

Name of Patient *

Date of Birth *

Email *

Signature

Date

Signature of Patient Representative

Required if the patient is a minor or an adult who is unable to sign this form.

Relationship to patient Representative of Patient

May we leave messages concerning your Appointments with the person that regularly answers your calls?

Yes No N/A

May we leave Messages on a voicemail?

Yes No N/A

Please print the names of the individuals with whom we may discuss your Medical History.

You must inform us In Writing if you wish to change the manner in which this office communicates to you. Thank you.

Patient’s Signature

Date