Acknowledgement of Receipt of Privacy Notice

Please provide the patient or guardian's full name.
Please provide patient's date of birth.

Your privacy and the privacy of your protected health inforamtion is important to us.  To provide you with health care, we must share your protected health information. It will be used for treatment, payment, and our health care operations. 

Our Notice of Privacy Practice ("NPP") gives you information about how we may use and disclose your protected health information.  You have the right to review our NPP before signing this Acknowledgement. 

Our privacy practices may change over time.  If we change our NPP, we will provide you with a new copy the next time you receive care. 

You must agree to the Terms & Conditions to submit this form online.
Please provide an electronic signature.