WEST END PEDIATRICS, P.C.

Written Acknowledgement Form

Our Notice of Privacy Practices provides information about how we may use and disclose Protected Health Information (PHI) about you.  As provided in our notice, the terms of our notice may change.  If we change our notice, you may obtain a revised copy.

I, ____________________________________  (please print name) have received a copy of  West End Pediatric, P.C.'s  Notice of Privacy Practices.

I have had an opportunity to read the Notice of Privacy Practices.

I understand that I may ask questions to West End Pediatrics, P.C.  if I do not understand any information contained in the Notice of Privacy Practices.
 

___________________________________  (Please list additional children below)
Patient Name or Patient Signature

___________________________________
Patient Name		 ___________________________________
Patient Name
___________________________________
Patient Name		 ___________________________________
Patient Name
___________________________________
Patient Name		 ___________________________________
Patient Name
  ___________________________________
Signature of Authorized Representative of  Patient(s)
  ___________________________________
Relationship to Patient(s)
  ___________________________________
Date

 4/14/03