Forms in English

Child Registration Form

LRH Release-Authorization Form 

Confidentiality Preference

Authorization to Use or Disclose PHI 

 

The following two forms are related to the Notice of Privacy Practices (NPP). The first document is the Notice of Privacy Practices and the second document is the Acknowledgment of Receipt of the NPP.

The only form that needs to be signed is the Acknowledgment.  By signing this form, you state that we have made the Notice of Privacy information available to you.

HIPAA-Notice of Privacy Practices 

Notice of Privacy Practices Acknowledgment 

 

Additional Information

Patient Rights and Responsibilities