Acknowledge Receipt of Service Description Brochure and HIPAA Privacy Practices

I have been offered brochures with Service Descriptions and Center Associates’ HIPAA Privacy Notice and understand that I may receive a copy of these documents at my request.

Patient''s Full Name *

Patient's Date of Birth * +

Signature Acknowledge Receipt of Service Description Brochure and HIPAA Privacy Practices *

clear

Todays Date * +

Full name of signer (printed) *

Relationship to Patient *

Self

Parent

Guardian

Other Other

At your request, you may receive a copy of this document.

Center Associates

3809 South Center St.

Marshalltown, IA 50158