You may refuse to sign this acknowledgment & authorization. In refusing we may not be allowed to process your insurance claims.
(This includes your spouse, children, step parents, grandparents and any care takers who can have access to this patient's records):
The undersigned acknowledges receipt of a copy of the currently effective Notice of Privacy Practices for this healthcare facility. A copy of this signed, dated document shall be as effective as the original. MY SIGNATURE WILL ALSO SERVE AS A PROTECTED HEALTH INFORMATION DOCUMENT RELEASE SHOULD I REQUEST MY MEDICAL RECORDS BE SENT TO OTHER ATTENDING DOCTOR/ FACILITYS IN THE FUTURE.
We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.