LCOH - ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

  • ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

    We are legally required to provide you with a copy of our NOTICE OF PRIVACY PRACTICES the first time you receive care at UC Health. If you are here for emergency medical treatment, you will be given a copy as soon as possible.

    Patient or Patient’s Legal Representative:

    Check appropriate box and sign.

    Patient or Patient's Legal Representative has:

  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY