Acknowledgement of Receipt of Notice of Privacy Practices
Tsung & Virmani Medical Group, Inc.
Privacy Officer: Jaya Virmani, M.D., 650-327-3000
I hereby acknowledge that I have reviewed a copy of this medical practice's Notice of Privacy Practices. I further acknowledge that a copy of the current notice will be available for me to review in the reception area, and that I will be offered a copy of any amended Notice of Privacy Practices at each appointment.
Signed: ______________________________ Date: __________________________
Print Name: __________________________ Telephone: _____________________
If not signed by the patient, please indicate:
- parent or guardian of minor patient
- guardian or conservator of an incompetent patient
- beneficiary or personal representative of deceased patient
Name of Patient: _________________________________________