Patient Registration Form Page 4

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Notice of Privacy Practices Acknowledgment
Associated Valley Obstetrics & Gynecology has a responsibility to protect the privacy of your health care information
and to provide a Notice of Privacy Practices that describes how your health care information may be used and
disclosed, how you can access your health care information, and whom to contact if you have questions, concerns, or
complaints.
We may change the Notice of Privacy Practices at any time, and you may contact Tracy Lewis, Administrator at
(425)251-3454 to obtain a current copy of the Notice of Privacy Practices or to ask questions.
By my signature below, I agree that I have received the Notice of Privacy Practices of Associated Valley Obstetrics
& Gynecology.
Printed name of patient
Patient or legally authorized individual’s signature
Date
Time
Printed name if signed on behalf of the patient
Relationship (
parent, legal guardian, personal representative)
This form will be retained in your medical record.
May we leave a message on your home recorder?
YES_____ NO_____ N/A______
May we leave a message on your cell voicemail?
YES_____ NO_____ N/A______
May we leave a message with people at your house?
YES_____ NO_____ N/A_____
May we discuss your test results with members at your house? YES_____ NO_____ N/A____
Please list family members with whom we may discuss test results, appointments, and your presence
at the office:
Name__________________________________________________________________
Name__________________________________________________________________
For Office Use Only
Office staff complete below:
I have attempted to obtain the patient’s signature on this form, but was not able to obtain it for the reason(s) listed
below:
Date: ____________________
Staff member initials: ______________________
Reasons:
May 2013

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