Notice to Patient


Acknowledgement of Receipt of Notice of Privacy Practices

This form will be retained in your medical record.



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 receipt of the Notice.

Patient Signature/Date of Birth:

I acknowledge that I have received and had the opportunity to review the Notice of Privacy Practices on the date below on behalf of ALBEMARLE FAMILY CHIROPRACTIC .

I understand that the Notice describes the uses and disclosures of my protected health information by ALBEMARLE FAMILY CHIROPRACTIC and informs me of my rights with respect to my protected health information.

Patient’s Signature or that of Legal Representative

Printed Name of Patient or that of Legal Representative

Today’s Date

If Legal Representative, Indicate Relationship



We have made every effort to obtain written acknowledgment of receipt of our Notice of Privacy from this patient but it could not be obtained because:

  • The patient refused to sign.
  • Due to an emergency situation it was not possible to obtain an acknowledgement
  • Communications barriers prohibited obtaining the acknowledgement
  • Other (please specify):

Employee Name/Date