Runnels Chiropractic

Acknowledgement of Receipt of 
Notice of Privacy Practices

This form will be retained in your medical record.


We are required to provide you with a copy of our Notice of Privacy Practices, Which state how we may use and/or discolse your information. Please sign this form to acknowledge receipt of the Notice.

Patient Name: 
Date of Birth:  

I acknowledge that I have received and had the opportunity to review the Notice of Privacy Practices on the date below on behalf of Runnels Chiropractic.

I understand that the Notice describes the uses and disclosures of my protected health information by Runnels Chiropractic and informs me of my rights with respect to my protected health information.

Patient's Signature or that of Legal Representative

Printed Name of Patient or that of Legal Representative

Today's Date 

If Legal Representative, Indicate Relationship