• Patient Acknowledgement and Receipt of Notice of Privacy Practices

    Pursuant to HIPAA and Consent for Use of Health Information

  • The undersigned does hereby acknowledge that he or she has received a copy of this office’s Notice of Privacy Practices Pursuant To HIPAA and has been advised that a full copy of this office’s HIPAA Compliance Manual is available upon request. The undersigned does hereby consent to the use of his or her health information in a manner consistent with the Notice of Privacy Practices Pursuant to HIPAA, the HIPAA Compliance Manual, State law and Federal Law. If patient is a minor or under a guardianship order (as defined by State law), signature of legal guardian is required.