NOTICE OF PRIVACY PRACTICES
ACKNOWLEDGMENT OF RECEIPT

 This form must be completed, either on paper or on-line, before we can provide
healthcare of any kind (in person, by telephone, or by e-mail) to your child after April 15, 2003.
Submitting this form does NOT signify that you agree, understand, or even
that you have read the notice, only that you have received a copy.

Name of person completing form:

First                                                 Last

Children's Medical Office Account #: 
This can be found on any office statement or receipt, on your child's school form.
Enter only digits to the left of, ignore digits after the decimal point
(i.e. 1234.1, 1234.2, and 1234.3 together need only one form with # entered as 1234).

Name(s) of child(ren): 
enter the first (and last if different from above) names of all children on account or in family.

By submitting this form you certify that you are the legal parent or guardian
 of the above children and that you have received a copy of the
Children's Medical Office Notice of Privacy Practices.

This form to be retained for no less than six (6) years.