Acknowledgement of Privacy Practices

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  • 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?
  • Patient Name
  • Patient Signature

  • 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.