HIPAA Information & Release FormPlease acknowledge your review and acceptance of the Notice of Privacy Practices and Patient Rights under HIPAA (August 1, 2017)HIPAA Notice Acknowledgement of Privacy Practices Name* First Last Email* I have received and reviewed a copy of Zen Den Medical's notice of Privacy Practices.YesNoPlease note that you may refuse to sign this documentSignatureDate* Date Format: MM slash DD slash YYYY PhoneThis field is for validation purposes and should be left unchanged.
