Acknowledgment of Notice of Privacy Practices

Please confirm you have received a copy of our Notice of Privacy Practices.

Notice of Privacy Practices. The Notice describes how your health information may be used and disclosed, and how you can access it. A copy is available on our website and was provided to you with this acknowledgment. View the Notice (PDF).

JavaScript is required to submit this form online. Please enable JavaScript, or download the printable PDF from the New Patient Forms page and fax it to (888) 965-0556.

I acknowledge that I have received a copy of the provider's Notice of Privacy Practices effective September 13, 2026.

Acknowledgment & Signature

I have received and had the opportunity to review the Notice of Privacy Practices.

Patient's Name (printed)

Date of Birth

Patient / Guardian Signature (type full name)

Date

Language assistance and accessible formats

Free language assistance services, and free auxiliary aids and services such as qualified interpreters and information in accessible formats, are available to you. Call (925) 289-9022 (TTY: 711) or ask our staff. See our notice of nondiscrimination.