Patient Acknowledgement of Notice of Privacy Practices – Dailey Pediatrics and Family Medicine

(As required by the Privacy Standards of the Health Insurance Portability and Accountability Act of 1996 (HIPPA)

I have reviewed a copy of the Notice of Privacy Practices of Dailey Pediatrics and Family Medicine, P.C. on the date indicated below.

I understand that if any changes are made to this Notice of PRivacy Practices, a revised copy of the notice will be posted in the office of Dailey Pediatrics and Family Medicine, P.C. I also understand that if I wish to receive a copy of this Notice of Privacy Practices or if I have any questions with regard to this Notice or Privacy Practices, I may ask an employee at Dailey Pediatrics and Family Medicine, P.C. or contact:

Dailey Pediatrics and Family Medicine, P.C.

310 Maple Drive

Vidalia, GA 30474

Fax: 912-805-2641

Signature of Patient/Legal Representative of Patient

Printed Name

Date

***If denied by patient include date denied on space below, reason denies, name of person who reviewed the denial.