Privacy Practices

Acknowledgement of Receipt of Notice of Privacy Practices

Colon and Rectal Surgeons of Greater Hartford, LLC

6 Northwestern Drive, Suite #305 Bloomfield, CT 06002

2400 Tamarack Avenue, Suite #200 South Windsor, CT 06074

Practice Manager, Privacy Official 860-242-8591 X 7965
Name of Patient
I hereby acknowledge that I received a copy of this medical practice's Notice of Privacy Practices. I further acknowledge that a copy of the current notice will be posted in the reception area, and that I may request a copy of any amended Notice of Privacy Practices at each appointment.
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