Acknowledgement of Receipt of Privacy Practices & Authorization for Release of Health Information (please print and sign)
After reading the ‘Notice of Privacy Practices’ above, please bring this completed form with you to your first appointment with us.
Acknowledgement of Receipt of Privacy Practices
(print and sign)
After reading the ‘Notice of Privacy Practices’ above, please bring this completed form with you to your first appointment with us.
Notice of Privacy Practices (read only)
Please carefully review this documentation.