REQUIRED ACKNOWLEDGMENT AND POLICY READING

Please review all of the mandatory-reading policy and notification documentation below and then digitally sign the HIPPA Documents and Supplier Standards Receipt at the bottom of this page acknowledging review and receipt.

PRE-APPOINTMENT REQUIRED FORMS

Patient Information Form
Patient Medical Profile Form

POLICIES & NOTIFICATIONS

HIPAA DOCUMENTS AND SUPPLIER STANDARDS RECEIPT

  • I the undersigned have received & reviewed the preceding documents on this day and I agree to the terms listed within them.
  • MM slash DD slash YYYY
  • NOTICE OF CONFIDENTIALITY: This digital document contains unconditionally private medical record information. Any improper use of the information contained herein constitutes a breach of patient medical confidentiality.

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