Acknowledgement of Receipt of Privacy Notice

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Patient First Name

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Patient Last Name

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I acknowledge that I have had an opportunity to review a copy and/or have been provided a copy of Prestige Medical Group’s “Notice of Privacy Practices”. This notice describes how Prestige Medical Group may use and disclose my protected health information, certain restrictions on the use of my healthcare information, and any rights I may have pertaining to my protected health information.

Date

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Relationship to Patient

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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.

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