Acknowledgement of Receipt of Notice of Privacy Practice

I have been offered a copy of the office's Notice of Privacy Practices. Cochran, Soares, and Associates provides this form to comply with HIPAA requirements. Please review the Notice of Privacy Practices before signing this document.
By signing this form, you acknowledge that we we may use and disclose your protected health information for treatment, payment, and healthcare operations. You have the right to request that we restrict how your protected health information is used or disclosed for treatment, payment, and healthcare operations.
MM slash DD slash YYYY

I give Permission for Cochran, Soares and Associates to:

Phone Number
Phone Number
Phone Number
Email

I give permission for you to speak with these individuals about my care:

Name
Name
Name