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: _________________________________________