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ACKNOWLEDGMENT OF RECEIPT OF PRIVACY PRACTICES

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Date of Birth:

I have been given the opportunity to review the notice of Privacy Practices for Middle Georgia OMS. I understand the terms stated herein are to remain in effect throughout my treatment with Middle Georgia OMS.

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YOU MAY REFUSE TO SIGN THIS ACKNOWLEDGMENT

The following people are authorized to speak on behalf of my account and/or treatment plan:

Name

Relation to Patient

Phone #

Permissions

Account

Treatment Plan

Name

Relation to Patient

Phone #

Permissions

Account

Treatment Plan

Name

Relation to Patient

Phone #

Permissions

Account

Treatment Plan

Messages with confidential information may be left at:

Message Locations

Home

Work

Cell Phone

E-mail

Other

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Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.

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