Acknowlegement of NOPP

Acknowlegement of Receipt of Notice of Privacy Practices

1-to-1 Pediatrics, Inc.
By signing this form, you acknowledge the receipt of the Notice of Privacy Practices of 1-to-1 Pediatrics and Epic Care. Our Notice of Privacy Practices provides information about how we may use and disclose your Protected Health Information (PHI We encourage you to read it in full.

Our Notice of Privacy Practices is subject to change. If we change our notice, we will provide you with the revised notice or you may obtain a copy of the revised notice by accessing our website at

www.1to1Pediatrics.com or contacting our office at (925) 362-1861.

If you have any questions about our Notice of Privacy Practices, please contact the Privacy Official, Andrew L. Nash, M.D. at the office.

I have been provided a copy of the document Notice of Privacy Policy. I have read it and had any questions answered to my satisfaction.
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Acknowlegement of Receipt of Notice of Privacy Practices