ASSURED RX HIPAA ACKNOWLEDGMENT FORM  
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* Last Name : * First Name : Middle Name :
* Date of Birth : (MM/DD/YYYY)

By signing below, I am acknowledging that:
• I am either the patient or the patient’s personal representative;
• I have received a copy of the "Notice of Privacy Practices".
• I understand that I may contact the person named in the Notice if I have questions about the content of the Notice.

* Signature of patient or parent/legal guardian/legally responsible person : * Date : (MM/DD/YYYY)
*Description of relationship to patient :
  
                                                                           
 
 
 
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