HIPAA Acknowledgement

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Acknowledgment of Reciept of Notice of Privacy Practices

Fauster-Cameron, Inc., reserves the right to modify the privacy practices outlined in the notice. Health care providers are required by law to give you the opportunity to complete this acknowledgement form after you have carefully reviewed the Notice of Privacy Practice. Completing this acknowledge form is voluntary. You are not required by law to complete the form.

To register, please fill in the information below and click the send button.
	Full Name:
	Date of Birth
	Telephone:
	Street Address:
	City:
	State:
	Zip:
	Email Address:
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