• To Our Patients:
    Federal law requires that we provide you with a copy of our Privacy Notice.

    The Privacy Notice explains how we may use and disclose health information about you. We ask that you sign this form for our records so that we may document your receipt of the notice.

    If you have questions about the Privacy Notice, please feel free to direct these to our Privacy Officer at any time. The name and contact number of the Privacy Officer is located in your copy of the Privacy Notice that is available on the website and in our office.








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  • IF PATIENT IS UNABLE TO ACKNOWLEDGE RECEIPT, STAFF MEMBER PROVIDING NOTICE TO COMPLETE THIS SECTION

    The Privacy Notice was provided to:








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