Acknowledgment of Receipt of Notice of Privacy Practices

Acknowledgment of Receipt of Notice of Privacy Practices
I hereby acknowledge that Bay Street Pediatrics has provided me with a copy of its Notice of Privacy Practices that describes how medical information about me may be used and disclosed, and how I can access this information. I understand that if I have questions or complaints I may contact 203-227-3674. I also understand that I am entitled to receive updates upon request if Bay Street Pediatrics amends or changes its Notice of Privacy Practices.
Patient's Name

First Name Last Name
Date

MonthDay Year
Date
Parent/Guardian's Name

First Name Last Name
Signature

Clear
Should be Empty: