ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
By signing this form, you acknowledge receipt of the Notice of Privacy Practices of Lodd Medical Group, S.C. Our Notice of Privacy Practices provides information about how we may use and disclose your protected health information.We encourage you to read it in full.
Our Notice of Privacy Practices is subject to change. If we change our notice, you may obtain a copy of the revised notice by calling Lodd Medical Group S.C. at 847-549-3979. If you have any questions about our Notice of Privacy practices, please ask our receptionist.
I acknowledge receipt of the Notice of Privacy practices of Lodd Medical Group S.C.
Print name of Patient:_________________________________________
Signature of Patient or Representative:____________________________
If Representative, give relationship:__________________________________