Notice of Privacy Practices

Patient Acknowledgement

Please complete this form and return either (1) online or (2) download and print your form to fax (212-308- 5242) or U.S. mail.

If submitting online and write in by hand if you are faxing or US mailing the completed form.The asterisk (*) means the field is optional. Thank-you.

Patient Name

Date of Birth

I have received this office's Notice of Privacy Practices written in plain language. The Notice provides in detail the uses and disclosures of my protected health information that may be made by this practice, my individual rights, how I may exercise these rights, and the office's legal duties with respect to my information.

I understand that this office reserves the right to change the terms of its Notice of Privacy Practices, and to make changes regarding all protected health information residing at, or controlled by this office. I understand I can obtain this office's current Notice of Privacy on request.

Please sign your name by typing it in the space below:

Signature

Date

Relationship to the patient (if signed by a personal representative of the patient):