Acknowledgment of Notice of Privacy Practices

Please confirm you have received a copy of our Notice of Privacy Practices.

Notice of Privacy Practices. The Notice describes how your health information may be used and disclosed, and how you can access it. A copy is available on our website and was provided to you with this acknowledgment. View the Notice (PDF).

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I acknowledge that I have received a copy of the provider's Notice of Privacy Practices effective September 13, 2026.

Acknowledgement & Signature

I have received and had the opportunity to review the Notice of Privacy Practices.

Patient's Name (printed)

Date of Birth

Patient / Guardian Signature (type full name)

Date