We encourage you to read the privacy statement and the other two documents. We are required by HIPAA law to provide every patient (family) a copy. We allso need a signed statement that you have read and understand the document.
Please print and sign the that you have read the Privacy Acknowledgement Statement. Also print the Designation of Personal Representative form. You may send both to the address provided. HIPAA requires that we have this form in your child's/children's chart(s).