You may refuse to sign this acknowledgment & authorization. In refusing we may not be allowed to process your insurance claims.
The undersigned acknowledges receipt of a copy of the currently effective Notice of Privacy Practices for this healthcare facility. A copy of this signed, dated document shall be as effective as the original. MY SIGNATURE WILL ALSO SERVE AS A PROTECTED HEALTH INFORMATION DOCUMENT RELEASE SHOULD I REQUEST MY MEDICAL RECORDS BE SENT TO OTHER ATTENDING DOCTOR/ FACILITYS IN THE FUTURE.
We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.