HIPAA

ACKNOWLEDGEMENT OF RECEIPT OF PRIVACY PRACTICES

You may refuse to fill out this acknowledgement. By filling out this form, you are verifying that you have received a copy of this office’s Notice of Privacy Practices

I AM THE “PERSONAL REPRESENTATIVE” AND HAVE LEGAL AUTHORITY TO MAKE HEALTH CARE DECISIONS ABOUT THE FOLLOWING PATIENT:

  • Authorization of additional disclosure:

    I authorize the following individuals to have access to my health information.