This form must be completed by the individual whose protected health information is to be disclosed or by a parent or guardian if the person is a minor under state law.
List each person that you approve to receive information:
I understand that this consent may be revoked by me at any time. I understand why I have been asked to disclose this information and am aware that my patient rights are identified in the practice’s Notice of Privacy Practices.
ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
*You May Refuse To Sign This Acknowledgement*
I acknowledge that I have received a copy of this office’s Notice of Privacy Practices