Acknowledgement of Receipt of Notice of Privacy Practices for Parents or Patient Representatives

If you are the parent or personal representative of the Patient, by clicking and typing the names indicated below, you acknowledge on behalf of the Patient that you will receive an emailed copy of Expert Radiology's Notice of Privacy Practices.

I hereby acknowledge that I am the Parent or Representative of the Patient indicated below and am authorized to receive an emailed copy of Expert Radiology's Notice of Privacy Practices on their behalf.

Parent or Personal Representative's Name *

Email *

Patient Name *

State the nature of your relationship with the Patient and describe your authority to act for the Patient. *