10320 Memory Lane, Suite A
Chesterfield, Virginia 23832

(804) 748-9553

FAX (804) 748-0460

Acknowledgement of Receipt of Notice Of
Privacy Practices

* You May Refuse to Sign This Acknowledgement *

I, ,have received a copy of this office's Notice of Privacy Practices.

Patient Information

E‐mail:

Cellular:

Signature:

Use your mouse cursor or the tip of your finger to sign below

Date:

For Office Use Only

We attempted to obtain written acknowledgement of receipt of our Notice of Primary Practices, but acknowledge could not be obtained because:

Individual refused to sign

Communication barriers prohibited obtaining the acknowledgement

An emergency situation prevented us from obtaining acknowledgement

Other (Please Specify)

AUTHORITY TO DISCUSS
AND ANSWER QUESIONS

The office of Virginia Perio is expressly authorized to answer questions posed by the Personal Representatives listed below and openly discuss with them my condition, treatment, test results, prognosis, insurance claims/payments, any other financial matters, and all other information pertinent to my care, even if I am fully competent to ask questions and discuss my condition. This document constitutes a full authorization to disclose any Individually Identifiable Information to the Personal Representatives named in the Authorization.

Name of person authorized

Relationship

Name of person authorized

Relationship

Name of person authorized

Relationship

Signature:

Use your mouse cursor or the tip of your finger to sign below

Date:

Acknowledgement of Receipt of Notice Of Privacy Practices

Patient Information

Signature:

For Office Use Only

AUTHORITY TO DISCUSS AND ANSWER QUESIONS

Signature:

Acknowledgement of Receipt of Notice Of
Privacy Practices

AUTHORITY TO DISCUSS
AND ANSWER QUESIONS