Acknowledgement of Receipt of Notice of Privacy Practices

Acknowledgement of Receipt of Notice of Privacy Practices
I acknowledge that I was provided a copy of Weinstein Imaging Associates' Notice of Privacy Practices (available for viewing here).

By submitting the information below, you are electronically signing this form.
Patient's name*

First NameMiddle (Optional)Last Name
Patient's birth date*

MonthDayYear
Your name and relationship, if you are the patient's personal representative
Should be Empty: