Acknowledgement of Receipt of Notice of Privacy Practices
You May Refuse to Sign This Acknowledgement
I have received a copy of the Element Medical Imaging
Notice of Privacy Practices
I decline to receive a copy of the Element Medical Imaging Notice of Privacy Practices
I authorize person(s) below access to my medical file:
Signature of Patient
(required) – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button I understand and agree that this is a legal representation of my signature.