Advanced Back Center

Receipt of Notice of Privacy Practices Form





I, _________________________________, hereby acknowledge receipt of the physician’s Notice of Privacy Practices.  The Notice of Privacy Practice provides detailed information about how the practice may use and disclose my confidential information.  

I understand that the physician has reserved the right to change his privacy practices that are described in the Notice.  I also understand that a copy of any Revised Notice will be provided to me or made available upon request.  



Signed:______________________________________Date:_______________________ 


If you are not the patient, please specify your relationship to the patient______________






-Patient’s file