HIPAA & Supplier Standards Acknowledgement

HIPAA and Supplier Standards Acknowledgement

Active Life does not sell or share this information. It is used strictly for identification purposes.
I have reviewed the following documents: HIPAA Notice of Privacy Practices & Medicare’s Supplier Standards (if applicable), and Assignment of Benefits.
I hereby authorize release of information regarding the services I will receive from Active Life to the following (Select All that Apply): *

No One Spouse Parent
Patient Name *

First Name Last Name
Patient Date of Birth *

Month Day Year
Date
Patient Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Parent and/or Guardian Name *

First Name Last Name
Phone Number *
Email *
example@example.com
By signing below, I acknowledge that I have been provided and reviewed the HIPAA Policy, Medicare Supplier Standards, and Assignment of Benefits documents on this website.
Patient or Legal Guardian Signature (Firma): *

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HIPAA and Supplier Standards Acknowledgement