Acknowledgement of Receipt of Notice of Privacy Practices

I have read and understand the Notice of Privacy Practices provided to me regarding my child                                                    (insert patient’s name) by Indianapolis Independent Pediatricians, P.C.  I understand that a personal copy is available to me at any time upon my request.  By signing this acknowledgment, I am consenting to Indianapolis Independent Pediatricians’ use and disclosure of my child’s protected health information (or my own, if I’m over 18 years old) to carry out treatment, payment, and healthcare-operations.

Signature                                                                 Date                                            

Printed Name                                                          Relationship to Patient                  

Please list those people authorized by you to accompany your child (or you, if you are not a minor) and receive information regarding the health of your child

(or you if you are the patient).  Listing the person give them authority to receive protected health information regarding the patient either in person, by mail, or by telephone.   Please list the relationship of the person in reference to the patient.

Name of Authorized Person                                      Relationship to Patient