CCMZ01 Notice of Privacy Practices Acknowledgement Form

C & C Medical Associates, PLLC
NOTICE OF PRIVACY PRACTICES - ACKNOWLEDGEMENT

Patient Name*

First NameMiddle NameLast Name

Date of Birth*

Date

We keep a record of the health care services we provide you. You may ask to see and copy that record. You may ask to correct or amend that record. We will not disclose your record to others unless you direct us to do so or unless the law authorizes or compels us to do so. You may see your record or get more information about it by contacting a staff member.

Our Notice of Privacy Practices describes in more detail how your health information may be used and disclosed, and how you can access your information.

By my signature below, I acknowledge receipt of the Notice of Privacy Practices.

Digital Signature Authorization:*

I certify that I am the person represented on this form or I have the legal authority to sign on their behalf. I also understand that the digital signature below is a valid legally binding signature.

Patient or legally authorized individual signature*

Name if signed on behalf of the patient

First NameLast Name

Relationship to Patient (parent, legal guardian, personal representative)

This form will be retained in your medical records.