Notice to Patient
We are required to provide you with a copy of our Notice of Privacy Practices, which states how we may use and/or disclose your health information. In addition to the copy we will provide you, copies of the current notice are available by accessing our website at arborpediatrics.com
Please sign this form to acknowledge receipt of the Notice of Privacy Practices. You may refuse to sign this acknowledgement, if you wish.
I acknowledge that I have received a copy of the Notice of Privacy Practices.