Acknowledgement of Receipt of Notice of Privacy Practices

The Practice reserves the right to modify the privacy practices out­lined in the notice.

Signature

I have received a copy of the Notice of Privacy Practices for Louisville Center for Weight Loss LLC and Hurstbourne Family Care LLC.

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Name of Patient (Print or Type)

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Signature of Patient

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Date

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Signature of Patient Representative
(Required if the patient is a minor or an adult who is unable to sign this form)

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Relationship of Patient Representative to Patient