Acknowledgement Form

By signing below, I acknowledge that I have received a copy of my physician’s Notice of Privacy Practices and have therefore been advised of how health information about me may be used and disclosed by this practice, and how I may obtain access to and control of this information.

I consent to the use and disclosure of my health information to treat me and arrange for my medical care, to seek and receive payment for services given to me, and for the business operations of this practice, its physicians, and staff.

Print Name of Patient/Patient’s Personal Representative:

Signature of Patient/Patient’s Personal Representative:

Description of Personal Representative’s Authority:

I do not have to sign this authorization in order to receive treatment from Healthy Kids Pediatrics. I have the right to refuse to sign this authorization. When my information is used or disclosed pursuant to this authorization, it may be subject to redisclosure by the recipient and is no longer subject to the HIPPA Privacy rule. I have the right to revoke this authorization, except to the extent that the practice has acted in reliance upon this authorization. My written revocation must be submitted in writing to the Privacy Officer at: 675 Franklin Avenue, Nutley, NJ 07110.

Consent to Discuss Health Care

Patient Name:

Date of Birth:

Today’s Date:

I authorize:

to discuss my health care information with the individuals listed below.





I give permission to Healthy Kids Pediatrics to leave my health care information at the following number(s).






(For Appointment reminders only)

Signature of Patient, Parent, or Legal Guardian:

Printed Name:


If you have any questions about this notice or would like further information, please contact the Privacy Officer at Healthy Kids Pediatrics, Nicole Loguidice. For office use only: If the patient does not sign this acknowledgement and consent form, record here the good faith efforts made to obtain this acknowledgement and consent.

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