Acknowledgement of Receipt of Notice of Privacy Practices

I, , acknowledge and agree that I have received a copy of Integrative Pain Center of Alaska, LLC’s Notice of Privacy Practices.

PATIENT’S SIGNATURE:
DATE:

PATIENT LEGAL REPRESENTATIVE ( if applicable):
DATE:

PRINT NAME OF LEGAL REPRESENTATIVE:
RELATIONSHIP TO PATIENT:

FOR CLINIC USE ONLY:

Integrative Pain Center of Alaska, LLC made the following good faith efforts to obtain the above – referenced individual’s written acknowledgement of receipt of North of Privacy Practices:

(Identify the efforts that were made to obtain the individual’s written acknowledgement, including the reasons (if known) why the writte acknowledgement was not obtained.)