Diabetes & Thyroid Associates/Osteoporosis Center of Fredericksburg

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

The undersigned Patient or legally authorized representative (“Agent”) of the Patient acknowledges that he or she personally received a copy of the Diabetes & Thyroid Associates/Osteoporosis Center of Fredericksburg Notice of Privacy Policies on the date indicated below.

Signature: ______Date: ______

Patient: ______

Information about Agent (attach appropriate documentation):

Agent: ______

Title: ______

List any persons whom you authorize us to give test results, medication changes or other medical information to: Person _ Relationship phone number

______

Do you grant permission for us to leave messages about your healthcare such as lab results and medications on your home answering machine, office voice mail, cell phone voice mail or by email? ***Mark through any that you do not authorize.

______Patient Signature Date