As per the Health Information Portability and Accountability Act effective since April 1, 2003, we are required to present each patient with a copy of our Notice of Privacy Policy. This notice outlines the manner in which health information may be used and how you can obtain access to this information. You may view the privacy notice by clicking on the link below.


Download Notice of Privacy Policy




We are also required to obtain acknowledgement of receipt of the privacy notice. Patients may print, sign and date this form to bring in to an appointment. You are only required to sign on the line that says "patient signature." You may fill out the Records Release Authorization portion if you wish your records to be released to someone other than yourself or the physician who referred you to us. Please note that you are not required to read the Notice of Privacy Policy before signing, as your signature only acknowledges that you received a copy of the Privacy Policy, that you consent to treatment and that you understand that your insurance company will pay us directly for services rendered.


Download Acknowledgement Form