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