Notice of Privacy Practices with Receipt of NPP

Patient Name:

Date of Birth:

MRN:

Printed name of authorized representative (if applicable)

Date

*Authorized representatives include:
• Parent of a Minor
• Legal Guardian (copy of documentation may be needed)
• Personal Representative (copy of documentation may be needed)
• Person under a durable medical Power of Attorney (POA) (copy of documentation may be needed)

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Time

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