Piedmont Obstetrics and Gynecology

Acknowledgement of Receipt

Our Notice of Privacy Practices provides information about how we may use and disclose protected health information about you.   If also provides information about your rights as a patient of our practice and whom you may contact at our office to ask questions about our privacy practices.

By signing this form, you agree that you have had the opportunity to read our Notice of Privacy Practices in it's entirety.

*********************************************************************************************

Patients Name___________________________________________

Signature__________________________________________

Date of Birth __________________________________

Today's Date__________________________

[ Home ] [ Up ] [ Notice of Privacy Practices ]