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:
TEXTAREA
(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.)
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