I acknowledge All Children Pediatrics, PLLC has provided me a copy its Notice of Privacy Practices,
which provides a detailed description of the uses and disclosures allowed, as well as other rights I have
regarding my protected health information.
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Signature of Patient or Parent/Guardian/Personal Representative
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Name of Patient or Parent/Guardian/Personal Representative
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Date
Please list all children along with date of birth:
Please mail this form to the following address:
HIPAA Compliance
All Children Pediatrics
400 Blankenbaker Pkwy. #200
Louisville, KY 40243