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Hipaa Notice Of Privacy Practices - Acknowledgement Form Three Rivers Ayurveda, Inc.

HIPAA Notice of Privacy Practices – Acknowledgement Form Three Rivers

Ayurveda, Inc.

I hereby acknowledge that I received a copy of this medical practice's Notice of Privacy

Practices. I further acknowledge that a copy of the current notice will be posted in the reception

area, or will be available during house calls, and that a copy of any amended Notice of Privacy

Practices will be available at each appointment.

I would like to receive a copy of any amended Notice of Privacy Practices by e-mail at:

______________________________________________________________________________

Signed: ___________________________________________ Date: ______________________

Print Name: _____________________________________

Telephone: ______________________________________

If not signed by the patient, please indicate relationship:

parent or guardian of minor patient

guardian or conservator of an incompetent patient

Name and Address of Patient:

______________________________________________________________________________

Hipaa Notice Of Privacy Practices - Acknowledgement Form Three Rivers Ayurveda, Inc.