Patient Privacy Form

Thomas W. Barnes, M.D., F.A.A.C.S.
Cosmetic Surgery and Laser Center
1441 Avocado Avenue, Suite 207, Newport Beach CA, 92660
Tel (949)719-9700 Fax (949) 760-9089

HIPAA PRIVACY PRACTICES ACKNOWLEDGEMENT

We are required by the Health Insurance Portability and Accountability Act (HIPAA) to both offer our patients a copy of our Notice of Privacy Practices and to obtain your signature that we did offer this document.

A copy of our Notice of Privacy Practices is available to you. If you would like to have one, please ask our office reception staff.

This Acknowledgment will be kept in your medical file. If you would like a copy, just ask.