Acknowledgement Form

I acknowledge that I have received the Notice of Privacy Practices for Nasseri Clinic of Arthritic and Rheumatic Diseases (NCARD). I understand that NCARD has the right to change its Notice of Privacy Practices from time to time and that I may contact NCARD at any time to obtain a current copy of the Notice of Privacy Practices.

Patient Name:

Date:

Print name of Legal Representative:

Relationship to Patient:

People to whom NCARD may release Patient Care or Billing Information:

1- Relationship:

1- Name:

2- Relationship:

2- Name:

3- Relationship:

3- Name:

4- Relationship:

4- Name:

I have attempted to obtain the patient’s signature on this form but was unable to for the following reason:

Date:

Initials: