Acknowledgement of Receipt of the Notice of Privacy Practices Disorders of the Foot and Ankle I hereby acknowledge that I received a copy of the medical practices Notice of Privacy Practices. I further acknowledge that a copy of the current notice will be posted in the reception area, and that I will be offered a copy of any amended Notice of Privacy Practices at each appointment. Signed: _____________________________________ Date: _________________________ Print Name: _________________________________ Telephone #: ___________________ If not signed by the patient, please indicate: Relationship: parent or guardian of patient guardian or conservator of an incompetent patient beneficiary or personal representative of deceased patient Name of Patient: _________________________________________________
Acknowledgement of Receipt of the Notice of Privacy Practices Disorders of the Foot and Ankle I hereby acknowledge that I received a copy of the medical practices Notice of Privacy Practices. I further acknowledge that a copy of the current notice will be posted in the reception area, and that I will be offered a copy of any amended Notice of Privacy Practices at each appointment. Signed: _____________________________________ Date: _________________________ Print Name: _________________________________ Telephone #: ___________________ If not signed by the patient, please indicate: Relationship: parent or guardian of patient guardian or conservator of an incompetent patient beneficiary or personal representative of deceased patient Name of Patient: _________________________________________________
Industrial-Injury-Patient-Information.docx