HIPAA Form

HIPAA Form
I acknowledge that I received Spectra Health's Notice of Privacy Practices and the Patient Bill of Rights that is effective as of January 26, 2004. I understand that I may ask questions about the Notice of Privacy Practices and the Patient Bill of Rights at any time. Spectra Health participates in Blue Alliance through ND Blue Cross. I can ask questions about this at any time.
Patient Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Signature*

Clear
Today's Date*

MonthDayYear
Date
Should be Empty: