Deborah L. Ungerleider, MD, LLC
Deborah L. Ungerleider, MD, LLC

HIPAA Acknowledgement

DEBORAH L. UNGERLEIDER, M.D., LLC

 

Receipt of Notice of Privacy Practices

Written Acknowledgement Form.

 

 

I, ____________________,

        Patient/Parent Name

 

have received a copy of Deborah L. Ungerleider, M.D., LLC’s Notice of Privacy Practices.

 

 

_________________________                    _________________

Signature of Patient/Parent                                  Date

 

________________________                      _________________

Relationship to Patient                                        Cell Phone#

 

________________________

Patient’s Name



To print out this form, click on the link below.

Hipaaacknowledgementform.doc
Microsoft Word document [23.0 KB]

Where to Find Us:

Deborah L. Ungerleider, MD, LLC

44 Godwin Ave Suite 100

Midland Park, NJ 07432

 

(201) 444-8389

 

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© Deborah L. Ungerleider, MD, LLC