Acknowledgement of Receipt of
Notice of Privacy Practices
This form will be retained in your medical record.
NOTICE TO PATIENT
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.
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.