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5 23 13 PATIENT ACKNOWLEDGMENT FORM - Piedmont HealthCare

5 23 13 PATIENT ACKNOWLEDGMENT FORM - Piedmont HealthCare 2025

5 23 13 PATIENT ACKNOWLEDGMENT FORM - Piedmont HealthCare Preview on Page 1

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The document is a Patient Acknowledgment Form from Piedmont HealthCare, confirming that the patient has received the Privacy Practices notice. It includes options for patients to authorize family or friends to access their medical records or to deny such access. Additionally, it allows patients to specify what type of information can be left as a message on their preferred phone number.

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Click ‘Get Form’ to open the 5 23 13 PATIENT ACKNOWLEDGMENT FORM in our editor.
Begin by entering your Patient Name and Date of Birth in the designated fields at the top of the form.
Fill in your Physician's name to ensure proper identification of your healthcare provider.
Sign the form to acknowledge receipt of Piedmont HealthCare’s Privacy Practices. Ensure you also date your signature.
Choose between Option 1 or Option 2 regarding access to your medical records. If selecting Option 1, provide the necessary details for any authorized individuals.
Indicate your preferred phone number and mark which type of information you allow to be left as a message.

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2015	4.8 Satisfied (52 Votes)
2014	4 Satisfied (55 Votes)

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