ACKNOWLEDGEMENT OF PRIVACY PRACTICE NOTICE & DESIGNATION OF DISCLOSURE FORM

Kintiroglou Pediatrics
1500 Pleasant Valley Way, Suite 301 West Orange, NJ 07052 973-243-0002
 
1. Acknowledgement of Privacy Practice Notice
I have received a copy of Kintiroglou Pediatrics Notice of Privacy Practices.
 
________________________________ _______________________
2. I wish to be contacted by the office via: Home Phone, Cell Phone Email
Home Phone: Cell Phone:
Email:
 
 
  • OK TO LEAVE MESSAGES WITH DETAILED INFORMATION
                HOME PHONE YES  OR  NO
                CELL PHONE YES  OR  NO
                EMAIL MESSAGES YES  OR  NO
 
 
  • LEAVE MESSAGE WITH CALL BACK NUMBER ONLY
YES  OR  NO
 
 
3. Designation of Certain Relatives, Close Friends & Other Caregivers
 
Kintiroglou Pediatrics may disclose certain of my health information to a family member or other caregiver because such person is involved with my healthcare or payment relating to my health care.
 
Kintiroglou Pediatrics will disclose only information that is directly relevant to the person’s involvement with my health care or payment related to my healthcare.
 
I designate the following persons listed below as persons involved with my healthcare or payment relating to my health care
1.
    PRINT NAME

RELATIONSHIP

DATE OF BIRTH

P. NUMBER
2.
    PRINT NAME

RELATIONSHIP

DATE OF BIRTH

P. NUMBER
 
_________________________
SIGNATURE OF PATIENT
______________________
DATE OF SIGNATURE
 

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