ACKNOWLEDGEMENT

Prestige Medical Group

Acknowledgement of Receipt of Notice of Privacy Practices

I acknowledge that I have received or have been offered a copy of Prestige Medical Group’s Notice of Privacy Practices. This notice describes how my protected health information (PHI) may be used and disclosed, my rights regarding my health information, and the responsibilities of Prestige Medical Group under federal and state privacy laws.

I understand that Prestige Medical Group reserves the right to change its Notice of Privacy Practices and that a current copy will be available at the practice and on the practice website.

Patient First Name

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Patient Last Name

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Date:

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By submitting your signature, the parties agree that this agreement may be electronically signed. The parties agree that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

Relationship to Patient (if not patient):

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