Acknowledgement of Privacy Practices
I hereby acknowledge that I have been offered Summit Orthopaedic Home Care's Notice of Privacy Practices.
Have you received a copy of the Notice of Privacy Practices?
Communication Preferences Regarding PHI
To assist in your care, it may be necessary to release our Protected Health Information to someone other than
yourself. To whom may we talk?
Name of authorized contact, and Relationship to Patient.
Preferred Phone Number
Do we have permission to leave voicemails?
Date of Patient Signature
Date Format: MM slash DD slash YYYY
Name of Person Acknowledging Receipt (if other than the patient), and Relationship to Patient.