Arbor Creek Current Patient Update Forms

HIPAA Notice of Privacy Practice

Notice to Patient: We are required to provide you with a copy of our Notice of Privacy Practices, which states how we may use and/or disclose your health information. Please sign this form to acknowledge reciept of this notice. You may refuse to sign this acknowledgement, if you wish.

I acknowledge that I have received a copy of this office's Notice of Privacy Practices and have read the contents. I understand that I am giving my consent to use and disclose my health care information to carry out treatment, education, payment activities and health care options
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Date

Month Day Year
Date
Medical Information Release
Name *
Date of Birth *
MM/DD/YYYY
Release of Information
I authorize the release of information including the diagnosis, records; examination rendered to me
Release to:
Name of person authorizing the release of information to *
Messages
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