Acknowledgement of Receipt of this Practice's Privacy Notice

I acknowledge that I have received, and/or reviewed the notice of the Privacy practices of this office. I am aware that I may receive a paper copy of this notice if I request it. In addition, I acknowledge that this notice of the practices Privacy Practices is posted in the office where I can review it if desired.

Signature of Patient, Patient Representative or Parent of Patients under age 18
*By typing your name in the signature box above, you are certifying that the information included in this form is true to the best of your knowledge. Typing your full name in the signature box above is the legal equivalent of your written signature, and will stand as such in all legal matters.
*If patient representative signs above, please describe the relationship to the patient:

Documentation of "Good Faith Effort"

Patient Name:
Email Address: