Privacy Acknowledgement

Privacy Practices Policy

ACKNOWLEDGEMENT 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 email) to your child.
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 and email of parent/guardian completing form:
First Name *
Last Name *
Email *
CMO Account Number *
This can be found on any office statement or receipt, or on any previous school form. Enter only digits to the left of decimal (ignore the decimal point and digits after the decimal point i.e. 1234.1, 1234.2, and 1234.3 together need only one form with number entered as 1234).
One patient per form, please.
Patient First Name *
Patient Last Name *
Patient Date of Birth *
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.
for internal use

Privacy Practices Policy