HIPAA Acknowledgment

I acknowledge that I have received a copy of the Notice of Privacy Practices as required under the Health Insurance Policy and Accountability Act (HIPAA). The notice I received describes how medical information about me may be used and disclosed and how I can get access to this information, including information on where to file a complaint regarding disclosure and use of protected health information under HIPAA.

Patient Information

 Patient Guardian/Custodian

Electronic Signature

Please type your full name into the area below and select today's date to acknowledge your receipt of our Notice of Privacy Practices.