EXHIBIT4 HIPPA FORM ___________________________ Hector L. Franco, M.D. RECEIPT OF NOTICE OF PRIVACY PRACTICES WRITTEN ACKNOWLEDGEMENT FORM |
I, _______________________________________, have received a copy or been given the opportunity to read a
paper or electronic (in Dr. Franco's Web Page) copy of Hector L. Franco, M.D.'s Notice of Privacy Practices.
__________________________________________ ________________________
Signature of Patient/Parent Date
A PHOTOCOPY OF THIS FORM (SIGNED) IS AS VALID AS THE ORIGINAL
paper or electronic (in Dr. Franco's Web Page) copy of Hector L. Franco, M.D.'s Notice of Privacy Practices.
__________________________________________ ________________________
Signature of Patient/Parent Date
A PHOTOCOPY OF THIS FORM (SIGNED) IS AS VALID AS THE ORIGINAL
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