Federal Law requires that we provide you with a copy of our Privacy Notice.
The Privacy Notice explains how we may use and disclose health information about you. We ask that you sign this form for our records so that we may document your receipt of the notice.
If you have questions about the Privacy Notice, please feel free to direct these to our Privacy Officer at any time. The name and contact number of the Privacy Officer is listed on your copy of the Privacy Notice.
Printed Patient Name:
Date of Birth:
I have received a copy of the Privacy Notice of this organization on today’s date.
Consent to Share
If you would like us to discuss your account or treatment plan with someone other than yourself, please indicate them below:
If patient is unable to acknowledge receipt, staff member providing notice needs to complete this section
Privacy Notice was provided to
Name:Relation to Patient:Date:
Patient was unable to acknowledge receipt of the Privacy Notice for the following reason:
**Submit before clicking through to the next form. Each form must be submitted individually.