Patient Acknowledgment of Receipt of Notice of Privacy Practices

I, the undersigned, hereby acknowledge that I have reviewed and received a copy of this office's Notice of Privacy Practices explaining:

1. How this office will use and disclose my protected health information.

2. My privacy rights with regard to my protected health information.

3. This office's obligations concerning the use and disclosure of my protected health information.

I understand that the Notice of Privacy Practices may be revised from time to time and that I an entitled to receive a copy of any new revised practices upon request.

I also understand that if I have questions or complaints, I may contact:

Ricardo M. Buenaventura, MD

7244 Far Hills Ave.

Centerville, OH 45459

937-395-1300

You may also contact the Secretary of the U.S. Department of Health and Human Services with any concerns regarding our privacy and security policies and procedures. Please contact our office for information on how to contact the U.S Department of Health and Human Services.

Patient or Personal Representative

Name: *

Today's Date: * +

Relationship to Patient: *

clear

For Office Use Only

We have made a good faith effort to obtain an acknowledgement from the patient regarding receipt of our Notice of Privacy Practices. In spite of these efforts, our office has been unable to obtain a signed acknowledgment of receipt for one of the following reasons:

Patient Refusal

Communication Barriers prohibited obtaining an acknowledgment

An Emergency Situation Prevented Us From Obtaining an Acknowledgment

Attempt was Made on