ACCOUNT_JOB_COMPANY

ACCOUNT_ADDRESS_SINGLE_LINE

ACCOUNT_PHONE_NOACCOUNT_EMAIL

Patient Acknowledgement Form

Notice of Privacy Practices

ロ I acknowledge that I have received, read and understood the Notice of Privacy Policy of ACCOUNT_JOB_COMPANY. The Notice describes how my medical information received by ACCOUNT_JOB_COMPANY may be used or disclosed by the ACCOUNT_JOB_COMPANY  and my right to access this information.

Authorize to Release Medical Information

ロ I understand and agree that ACCOUNT_JOB_COMPANY may use and disclose my personal health information to help provide healthcare, to handle billing, insurance and payment, and to take care of other health care operations. I also authorise ACCOUNT_JOB_COMPANY to send electronic communication which may contain protected health information to either my e-mail account or personal health record.

Payment Responsibility

ロI understand that all charges are due at the time of service, and that there are no refunds on consultations and/or treatments. I agree to pay ACCOUNT_JOB_COMPANY for all charges for the treatment and/or consultation provided to me, or my dependent.

Cancellation Policy

ロ I acknowledge that I have read and understood the cancellation policy of ACCOUNT_JOB_COMPANY i.e.

CANCELLATION_POLICY

By signing below, I acknowledge that I understand and will adhere to the Privacy, Payment, and Cancellation Policies of ACCOUNT_JOB_COMPANY

Patient Name:

Patient Signature:

Date:

 

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