(to be filed in patient's medical records)
I have been presented with a copy of the Notice of Privacy Practices, detailing how my health information may be used and disclosed as permitted under federal and state law, and outlining my rights regarding my health information.
Signed: ____________________________________ Date: _________________
Relationship (if not signed by patient): __________________________________
Presented on (date and time): ________________________________________
By (name and title): _________________________________________________
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