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:

Relationship:

- parent or guardian of minor patient

- guardian or conservator of an incompetent patient

- beneficiary or personal representative of deceased patient

Name of Patient: _________________________________________