Acknowledgement of Privacy

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Patient Name:_______________________________
_____________________
Date of Birth:
Acknowledgement of Privacy Practices
The privacy, security and confidentiality of your health information are important to us. Please let us know
how you prefer us to contact you with results or questions, or appointment reminders.
Please select and number in the order we should attempt:
Phone Number:
___
Home phone – Can we leave a message?
__ YES __ NO
_____________________
___
Cell phone – Can we leave a message?
__ YES __ NO
_____________________
___
Work phone – Can we leave a message?
__ YES __ NO
_____________________
___
Mail to home address?
___
Telephone and message to another person
___
Other
Please list any other persons to whom we may discuss your healthcare treatment and/or payment
information. Many patients take this opportunity to list a parent or guardian who often participates in their
healthcare decisions and payment.
Name: ______________________________Phone: _________________Relationship: ___________________
Name: ______________________________Phone: _________________Relationship: ___________________
By signing below, I acknowledge that I have received, read, and understand the Alabama A&M Student
Health Care Center Notice of Privacy Practices.
____________________________________
__________________________
Signature of Patient or Legal Representative
Date
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