HIPAA Acknowledge Receipt of Notice of Privacy PracticesPlease enable JavaScript in your browser to complete this form.Acknowledge Receipt of Notice of Health Information Practices I 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
