Betty H Yao, MD APC - Publicforms

Available Forms

Acknowledgement Of Receipt Of Notice Of Privacy Practices Agreement to pay, records release & privacy policy New Patient Information Records request form Updated Patient Information(for existing patients only) Well Check/Preventative Care

Acknowledgement Of Receipt Of Notice Of Privacy Practices

I acknowledge that I have received a copy of Dr. Yao's "Notice Of Privacy Practices". This notice describes how Dr. Yao may use and disclose my protected health information, certain restrictions on the use and disclosure of my healthcare information, and rights. I have regarding my protected health information.

Signature of Patient or Personal Representative: *

Date *

Relationship to Patient

* Required field