360core€¦ · i hereby authorize manouchehr nikpour, p.c. to receive and/or release any medical...

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Page 1: 360Core€¦ · I hereby authorize Manouchehr Nikpour, P.C. to receive and/or release any medical or other information that may be necessary for the medical care or processing of
Page 2: 360Core€¦ · I hereby authorize Manouchehr Nikpour, P.C. to receive and/or release any medical or other information that may be necessary for the medical care or processing of
Page 3: 360Core€¦ · I hereby authorize Manouchehr Nikpour, P.C. to receive and/or release any medical or other information that may be necessary for the medical care or processing of
Page 4: 360Core€¦ · I hereby authorize Manouchehr Nikpour, P.C. to receive and/or release any medical or other information that may be necessary for the medical care or processing of
Page 5: 360Core€¦ · I hereby authorize Manouchehr Nikpour, P.C. to receive and/or release any medical or other information that may be necessary for the medical care or processing of

[NAME OF PRACTICE]

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 [NAME OF PRACTICE]'s Notice of Privacy Policies on the date indicated below.

Signature: Date:

Patient:

Information about Agent (attach appropriate documentation):

Agent:

Title:

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