ACKNOWLEDGEMENT OF RECEIPT OF PRIVACY NOTICE

*Print, fill out and bring with you to your appointment

 

 By signing this form, you acknowledge that Physician Laser Centers has given you a copy of its Privacy Notice, which explains how your health information will be handled in various situations.  We must try to have you sign this form on your first date of service with us after April 14, 2003.

If your first date of service with us was due to an emergency, we must try to give you this notice and get your signature acknowledging receipt of this notice as soon as we can after the emergency.

Check all that are true:

[  ]        I have received Physician Laser Centers Privacy Notice.

[  ]        Physician Laser Centers has given me the chance to discuss my concerns and questions about the privacy of my health information.

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Patient Signature                                                    Date

Physician Laser Centers staff should complete if Acknowledgement Form is not signed:

Does patient have a copy of the Privacy Notice?

[  ]  Yes                        [  ]  No

Please explain why the patient was unable to sign an acknowledgement form and Physician Laser Centers Privacy efforts in trying to obtain the patient’s signature: