Acknowledgement of Receipt s1
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Acknowledgement of Receipt
I acknowledge that I have been informed of the Notice of Privacy of Practices of Grand Rapids Ear, Nose and Throat, P.C. and understand that a copy of this plan is available to me. I further acknowledge that I have had an opportunity to ask questions about this policy.
Date: ______[Signature]
______[Name of Patient]
If this acknowledgement is not signed by the patient, please print the information set forth below:
______[Name of person signing]
______[Relationship to the Patient]
I authorize Grand Rapids Ear, Nose and Throat, P.C. to release any of my personal medical information to: (please list any person or persons you wish to have access to your medical information. If none, please answer none).
______Relationship ______
______Relationship ______
______[Patient or Legal Guardian Signature] Date