Privacy Practices (Form 3 of 5) Please download and review Alamo ENT Associates Notice of Privacy Practices. Acknowledgement of Privacy Practices Step 1 of 2 50% ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES (VIEW WITH LINK ABOVE)* I acknowledge that I have received a copy of Alamo ENT Associates’ Notice of Privacy Practices. This notice describes how Alamo ENT Associates may use and disclose my protected health information, certain restrictions on the use and disclosure of my healthcare information, and rights I may have regarding my protected health information.Electronic Signature* The parties agree that this form may be electronically signed. The parties agree that the typing their name in the signature box is the same as a hand written signature for purposes of validity, enforceability and admissibility. I hereby authorize Alamo ENT Associates to release health information to the following names*NameRelationship I hereby authorize Alamo ENT Associates’ providers to treat my minor child(ren) in the event I am unable to accompany him/her/them. The following people have my permission to bring my minor child(ren) in to Alamo ENT Associates:*NameRelationship Patient's/Parent's or Legal Guardian's Full Signature* The parties agree that this form may be electronically signed. The parties agree that the typing their name in the signature box is the same as a hand written signature for purposes of validity, enforceability and admissibility.
