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.
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.
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
Uses and Disclosures
Your protected health information can be disclosed without your written authorization in certain limited
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.
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.