Acknowledgement of Receipt of Notice of Privacy Practices

Acknowledgement of Receipt of Notice of Privacy Practices 2017-10-12T10:48:57+00:00
  • , acknowledge and agree that I have received a copy of Integrative Pain Center of Alaska, LLC’s Notice of Privacy Practices.
  • 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.)
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