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PATIENT ACKNOWLEDGEMENT OF

RECEIPT OF NOTICE

I hereby acknowledge receipt of the Notice of Privacy Practices for Taylor Chiropractic regarding my health information. I have been informed and understand the manner in which my health information shall be maintained, utilized and disclosed by Clinic and my respective rights contained there in. I also understand that the Notice furnished to me is subject to change at any time. I am aware that I may obtain a current copy of this Notice at any time by contacting Darrin M. Taylor, DC at 1185 Westwood Drive, Van Wert, Ohio 45891.
My signature herein below constitutes full acknowledgement that I have furnished a copy of the Notice of Privacy Practices for Taylor Chiropractic.

_______________________________________ ____________________________

Patient Signature Date

_______________________________________ _____________________________

Patient’s Legal Representative Date

if required

If signed by patient’s legal representative, please state representative’s relationship to patient:

_____________________________________________

First Name^*
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Taylor Chiropractic
Friendly Affordable Care	(419) 232-4470