Acknowledgement of Receipt of Notice of Privacy Practices

(You may refuse to sign this acknowledgement)

Individual's Name: {{patient_first_name}} {{patient_last_name}} Birthdate: {{patient_birthdate}}

By signing below, I acknowledge that I have been given the opportunity to request a copy of the Notice of Privacy Practices.

Signature of Individual:

Signature of Witness/ Provider:

Date: {{current_date}}

Notice of Privacy Practices is prominently displayed within the facility.

Medical Services provided by Primary Medical of KY, P.S.C., Elite Health Services, P.A., Co., Primary Medical of IN, P.C.
2025.06.18

Leave this empty:

Your legal name

Your email address

Please Confirm full name and signature.

Draw your signature with your mouse, tablet or smartphone Clear

I agree that I am and I agree this is a legal representation of my signature for all purposes just the same as a pen-and-paper signature

I agree that I am and I understand this is a legal representation of my signature

(Awaiting Signature)

Alex AssessmentTest
(Awaiting Signature)

Signature Certificate

Acknowledgement of Receipt of Notice of Privacy Practices (Telehealth)

Unique Document ID: 160b12fd077783b82f1f5ed90b7b363f58876e07

Build. Track. Sign Contracts.

Alex AssessmentTest

Party ID: 6673d599-4b58-4710-8a47-9f5cb69caf4e

Awaiting signature

Party ID: f77b9040-fd92-435e-b963-8872205d5f9e

Awaiting signature

Timestamp

Audit

2026-08-25 16:13:21 UTC

Document Acknowledgement of Receipt of Notice of Privacy Practices (Telehealth)
Uploaded by EnnuLife - docs-admin-ennulife@ennulife.com
IP: 0.0.0.0