Acknowledgement
of Receipt of Notice of Privacy Practices
Kyle D.
Parish, MD, PSC reserves
the right to modify the privacy practices outlined in the notice.
Signature
I have received a copy of the Notice of
Privacy Practices for Kyle D. Parish,
MD, PSC
____________________________________________________________________________
Name of Patient (Print or Type)
____________________________________________________________________________
Signature of Patient
____________________________________________________________________________
Date
____________________________________________________________________________
Signature of Patient Representative
(Required if the patient is a minor or an
adult who is unable to sign this form)
____________________________________________________________________________
Relationship of Patient Representative to
Patient