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Columbia Medical Practice

Notice of Privacy Practices

ACKNOWLEDGEMENT FORM

I acknowledge that I have been advised of the Notice of Privacy Practices for Columbia Medical Practice. (CMP). I understand that CMP has the right to change its Notice of Privacy Practices from time to time and that I may contact CMP at any time to obtain a current copy of the Notice of Privacy Practices.

Date _______________________________

Account Number _____________________

Patient Name (print)________________________________________________________

Signature of Patient

/ Legal Representative ______________________________________________________

Relationship to Patient ______________________________________________________

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For Office Use Only

I have attempted to obtain the patient’s signature on this form, but was not able to for the following reason:

Date: _____________________________  Initials: _________________

CMP has been recognized by the National Committee for Quality Assurance for meeting the highest standards and performance benchmarks in the use of electronic medical records to enhance patient care.