Acknowledgement of Receipt of Notice of Privacy Practices

(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): _________________________________________________

George P.H. Young, M.D., F.A.C.S., P.C.

1060 Fifth Avenue
(at 7 East 87th Street)
New York, NY 10128
Tel: 212.876.9811
Fax: 212.876.9806