Patient Acknowledgement
Patient Name: _______________________________________
Date of Birth: ________________________________________
I have received this practice's Notice of Privacy Practices written in plain language. The Notice provides in detail the uses and disclosures on my protected health information that may be made by this practice, my individual rights, how I may exercise these rights, and the practice's legal duties with respect to my information.
I understand that this practice resserves the right to change the terms of its Notice of Privacy Practices, and to make changes regarding all protected health information resident at, or controlled by, this practice. I understand I can obtain this practice's current Notice of Privacy Practices on request.
Signature: ________________________________________________
Date: ____________________________________________________
Relationship to patient (if signed by a personal representative of patient):
___________________________________________
Snyder/Stuart Podiatry Centers
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16087 Manchester Road Ellisville, MO 63011 Tel: 636.230.3883 Fax: 636.230.3884 view map |
12410 Lusher Road St. Louis, MO 63138 Tel: 314.355.2230 Fax: 314.355.2233 view map |
600 Medical Drive Suite 216 Wentzville, MO 63385 Tel: 636.230.3883 view map
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