Acknowledgement of Notice of Privacy Practice HIPAA Mobile App

Included Fields

Customize to add, remove, or edit any of the fields below.

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  I have been presented with a copy of the Notice of Privacy Practices for the office of

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  detailing how my information may be used and disclosed as permitted under federal and state law.

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  Signed:

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  Date:

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  If not signed by patient, please indicate relationship to patient (e.

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  Patient:

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  Relationship:

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