<p> Acknowledgement of Receipt</p><p>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.</p><p>Date: ______[Signature]</p><p>______[Name of Patient]</p><p>If this acknowledgement is not signed by the patient, please print the information set forth below:</p><p>______[Name of person signing]</p><p>______[Relationship to the Patient]</p><p>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).</p><p>______Relationship ______</p><p>______Relationship ______</p><p>______[Patient or Legal Guardian Signature] Date</p>