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Capitol Ear, Nose and Throat
Garner Ear,
Nose and Throat
Wake Forest Ear, Nose and Throat
Fax : (919) 787-8841
Acknowledgement of Receipt
of Notice of
Privacy Practices
Patient Name & Address:
_______________________________________
____________________________________________________________
____________________________________________________________
I have received a copy of the Notice of Privacy Practices
for the above named practice.
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_______________________________ |
_____________________ |
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Signature |
Date |
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For Office Use Only
We were unable to obtain a written acknowledgement of
receipt of the Notice of Privacy Practices because:
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An emergency existed & a signature was not
possible at the time. |
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The individual refused to sign. |
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A copy was mailed with a request for a signature by
return mail. |
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Unable to communicate with the patient for the
following
reason:
_____________________________________________________
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Other:
_____________________________________________________
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Prepared By |
_____________________________________________________
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Signature |
__________________________________________
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Date |
__________________________________________
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Instructions
Print this form then fax or
mail it.
Fax: 919-787-8841
Mail Address:
West Raleigh Office
3100 Blue Ridge Road, Suite 201
Raleigh, NC 27612
New
Patients Only......click
here for our online patient registration form |
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