Acknowledgment of Receipt of Notice of Privacy Practices
I certify that I have received a copy of Durretts Notice of Privacy Practices. The Notice of Privacy Practices describes the types of uses and disclosures of my protected health information that might occur in my treatment, payment of my bills or in the performance of Durretts health care operations. The Notice of Privacy Practices also describes my rights and Durretts duties with respect to my protected health information. The Notice of Privacy Practices is posted in the waiting area and on Durrett's web site at www.durrettsoandp.com.
Durrett reserves the right to change the privacy practices that are described in the Notice of Privacy Practices. I may obtain a revised Notice of Privacy Practices by calling the office and requesting a revised copy be sent in the mail, asking for one at the time of my next appointment, or accessing Durrett's web site.
Signature of Patient or Personal Representative
Printed Name of Patient or Personal Representative
Description of Personal Representative's Authority (Relationship)
The following individuals may have access to my PHI:
_Spouse _ Child/Children _ Parent(s) _ Guardian(s) _ Other
__ I refuse to sign this form