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Columbia Medical Practice
Notice of Privacy Practices
ACKNOWLEDGEMENT FORM
I acknowledge that I have been advised of the Notice of Privacy Practices for Columbia Medical Practice. (CMP). I understand that CMP has the right to change its Notice of Privacy Practices from time to time and that I may contact CMP at any time to obtain a current copy of the Notice of Privacy Practices.
Date _______________________________
Account Number _____________________
Patient Name (print)________________________________________________________
Signature of Patient
/ Legal Representative ______________________________________________________
Relationship to Patient ______________________________________________________
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For Office Use Only
I have attempted to obtain the patient’s signature on this form, but was not able to for the following reason:
Date: _____________________________ Initials: _________________
