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Acknowledgement of Receipt of Privacy Policy Notice

This document acknowledges that you have received a copy of the Notice of Privacy Practices. This document is not a contract, authorization, release, or consent form. This document will remain in your records.

(Patient), Acknowledge that I have received a copy of the Notice of Privacy Practices.

Acknowledge that I have received a copy of the Notice of Privacy Practices.

If the patient is a minor, a parent or legal guardian must sign.

If the patient is NOT a minor, but under the care of a friend, relative, or caregiver.


Notice of Policy Practices

All information that is obtained from you by this office is protected and kept confidential. Every reasonable measure to prevent unauthorized disclosure of your protected health information is practiced.

Uses and Disclosures

Certain Circumstances

Your protected health information can be disclosed without your written authorization in certain limited circumstances:

For any purpose other than treatment, obtaining payment, healthcare operations, or certain circumstances, we will ask for your written authorization before using or disclosing your protected healthcare information. If you choose to sign an authorization to disclose protected health information, you can revoke that authorization in writing at any time.

Patient Rights

Changes to this Notice: We reserve the right to change privacy practices and the conditions of this notice at any time and without prior notice. In the event of changes, and updated notice will be posted and a copy will be made available to you.