HIPAA - Nephrology Associates of Dayton

ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

You may refuse to sign this acknowledgment

Nephrology Assocciates of Dayton, Inc. respects your privacy and only uses or discloses your medical information when necessary or appropriate. Our Notice of Privacy Practices describes all potential uses and disclosuresof your health information by our practice and outlines your medical privacy rights.I have been provided with a Notice of Privacy Practices (available in the medical office waiting area), which provides a more complete description of how my potential health information may be used or disclosed.I understand that Nephrology Associates of Dayton reserves the right to change their notice and information practices and that I may obtain a copy of the revised notice by requesting a copy from the medical office.

*Patient Name

Date of Birth*

Name

Relationship

Phone

Name

Relationship

Phone

Name

Relationship

Phone

If we are unable to reach you, may we leave a message on your "HOME" phone number?YesNo

If we are unable to reach you, may we leave a message on your "CELL" phone number?YesNo

May we send you email reminders? If yes, please provide your email