HIPAA Acknowledge Receipt of Notice of Privacy PracticesAcknowledge Receipt of Notice of Health Information PracticesI hereby acknowledge that I have received a copy of the HIPAA Omnibus Notice of Privacy Practices.I have read and understood this Notice and, I have had an opportunity to ask questions about the use and disclosure of my health information.By my signature below, I hereby knowingly and voluntarily authorize Hearing Dynamics LLC to use or disclose my information in the manner described in this Notice.Print this notice.Signature of Patient (or Personal Representative) *Clear Signature(Click down and drag your cursor to write your signature.)Patient's Name *FirstLastName of Personal Representative (if applicable)FirstLastEmail *Effective Date *NameSubmit Your Acknowledgement
