Receipt Of Notice Of Privacy Practices Form

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Ad- Park Pediatrics S.C.

Notice of Privacy Practices Form

Receipt of Notice of Privacy Practices Form

I, ___________________________________, hereby acknowledge receipt of Ad-Park

Pediatrics Associates, S.C.’s Notice of Privacy Practices. The notice of Privacy Practices provides

detailed information about how the practice may use and disclose my confidential information

as well as pertinent office policy.

I understand that Ad-Park pediatric Associates, S.C. reserves the right to change their

privacy practice that are described in the Notice. I also understand that a copy of any revised

Notice will be available for review upon request.

Signed: _____________________________________________ Date: ____________________

Relationship to Patient(s): __________________________________

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