Clymer Healing Center Woodlands Healing Research Center

5916 Clymer Rd., Quakertown, PA 18951 * 215-536-8001 * Fax 215-536-9099

5724 Clymer Rd., Quakertown, PA 18951 * 215-536-1890 * Fax 215-529-9034
 

 HIPPA Notice of Privacy Practices Signature Form

 
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THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE

USED AND DISCLOSED

AND HOW YOU CAN GET ACCESS TO THIS INFORMATION

Patient Name:    
Personal Representative Name: Relationship:

 

Woodlands Healing Research Center has provided the above named: Patient Personal Representative
 with the Notice of Privacy Practices for Woodlands Healing Research Center.

 

Describe how notice was provided:
A copy was offered and the individual accepted the copy
A copy was offered and the individual refused the copy
Other:
   
Describe efforts to obtain signature on acknowledgment of notice form (for office use)
The patient/personal representative was asked to sign form and refused
Other:
   

Printed Name:

Date:

 

Signature

      
   
WHRC Representatives Initials:   (for office use only)

 

Click here to Return to HIPPA Notice Page Click here to Return to Woodlands Home Page
Click here to Return to New Patient Information Page