You may refuse to sign this acknowledgement & authorization. In refusing we may not be allowed to process insurance reimbursement paperwork or requests for information.
The undersigned acknowledges opportunity to review and/or receive a copy of the currently effective Notice of Privacy Practices for this facility. A copy is available in the office, on our website and by email to the client upon request. A copy of this signed, dated document shall be as effective as the original.
PLEASE LIST ANY OTHER PARTIES WHO CAN HAVE ACCESS TO YOUR HEALTH INFORMATION:
(This includes step parents, grandparents and any other care takers who can have access to this patients records):