119 West H Ave.

, North Little Rock, Arkansas 72116

Phone 501-772-3224 · Fax 501-771-7648

Patient Information Sheet

Last Name: _____________________ First Name: ____________________ Middle: _________

DOB: _____/______/______ SS #____________________ Marital Status: S M W D or Other

Gender: M F Home #________________Cell #________________ Appt Reminder Text or Call

Home Address: _______________________ City: ______________ ST: ______ Zip: _________

Employer Name: _________________Occupation: _____________ Work Number :__________

Spouse/Guardian

Last Name: __________________ First Name: ______________________ Middle: __________

Cell # _____________________ Relationship: __________________ DOB: ____/_____/______

EMERGENCY Contact: Name and Address of nearest relative or friend not living with you

Last Name: ___________________ First Name: ___________________ Relation: ___________

Home # __________________ Work # ______________________ Cell # __________________

Insurance Information: PRIMARY

Insurance: _________________________ ID # _________________________________

Insurance Information: SECONDRY

Insurance: __________________________ID # _________________________________

Responsible Party: Complete this section if you are not the patient but are the responsible for payment:

Responsible Party Name: ___________________________________ Relation: ______________

Home Address: ______________________ City: ____________ ST: _____ Zip: _____________

Home # _____________________ Cell # _____________________ Work # ________________

If my insurance company refuses payment for therapy service rendered by AR Lymphedema & Therapy
Providers, I understand that I am responsible for the full amount of each claim.

_______________________________________ ____________________
Patient/Parent/Responsible Party signature Date:
 119 West H Ave., North Little Rock, Arkansas 72116
Phone 501-772-3224 · Fax 501-771-7648

Arkansas Lymphedema & Therapy Providers

Are you currently or have you received skilled assistance in your home within the last six months?
(ie: nurse, home assistance, in-home therapy, etc.) Yes No

If yes, please list type of service & agency provided by: __________________________

________________________________________________________________________________

It is your responsibility to inform our office if you are receiving Home Health services so that we can
make the appropriate financial arrangements for your treatment. Failure to do so could result in
you being responsible for all treatment costs. As a Medicare beneficiary, you are subject to possible
payment liability if you obtain services from anyone other than your primary HHA.

_____________ (initial)

Are you currently receiving any other therapy services? Yes No

Most private insurance carriers will only pay for one physical therapy provider per day. If you are
in treatment with other physical therapy providers, it is your responsibility to schedule on non-
concurrent days. _____________(initial)

Have you received any other therapy services in the current calendar year? Yes No

Is injury result of a work-related accident or automobile accident? Yes No

Financial Policy:
Thank you for choosing us as your physical therapy provider. We are committed to your treatment being
successful. Please understand that payment on your bill is considered a part of your treatment. The
following is a statement of our Financial Policy, which we require you to read and sign prior to any
treatment.

Insurance Patients: Your health insurance is a contract between you and your insurance company; we are
not a party to this contract. Patients are responsible for understanding their health insurance coverage and
benefits. If you have provided all necessary insurance information to our office, then we will bill your
insurance company as a courtesy. However, you are financially responsible for any charges not covered by
your insurance plan. Actual patient responsibility can only be determined once your insurance company
has processed a claim. If you have further financial obligation than what we collected in the office, you
will receive a statement from our billing company. We require your co-payment to be paid at the time of
service. We accept cash, debit/credit cards, and personal checks.

Self-Pay Patients: You are required to sign a self-pay agreement letter. You are responsible for
payment of services at each visit. Please speak with the office manager for available payment options.

I have read the Financial Policy. I understand and agree to the Financial Policy
____________________________________________________ ______________________
Signature of Patient or Responsible Party Date
 119 West H Ave., North Little Rock, Arkansas 72116
Phone 501-772-3224 · Fax 501-771-7648
“The ONLY Independent Arkansas Therapy Clinic Offering Services by a Certified Lymphedema Specialist.”

Consent for Release of Information

Client’s Name: Date of Birth: ____________

I hereby give authorization to Arkansas Lymphedema & Therapy Providers to

release information and receive information regarding needs and services from the
following:

Physician: _____

Primary Care Physician: _______________________________________

Hospital:

Other: ______________________________________________________

Authorization for Treatment

I authorize treatment be given as ordered by my physician.

Assignment of Benefits
I authorize payment of medical benefits be paid directly for services rendered.

_________________________________ ___________
Signature of Patient/Parent/Guardian Date
 119 West H Ave., North Little Rock, Arkansas 72116
Phone 501-772-3224 · Fax 501-771-7648

Consent/Authorization to Bill Insurance

I hereby give consent to the physical/occupational therapists at Arkansas Lymphedema &

Therapy Providers (hereafter to be referred to as ALTP) to provide therapy services to myself for
conditions warranted by physical/occupational therapy treatment.

If my account with ALTP is to be paid by health insurance, workman’s compensation, or

automobile insurance, I hereby request and authorize my insurance company, or other
appropriate party, to pay directly to ALTP any proceeds payable under my policy(s) for the
professional and/or medical services rendered. All allowable benefits will be paid to ALTP
under my current insurance policy(s) as payment toward the total charges assessed to me for
ALTP’s professional services.

I agree to pay to ALTP any allowable balance (for example, copays, deductibles, coinsurance)
accrued for professional services over and above the insurance payment.

I agree that it is my responsibility to know and understand my insurance policy regarding

referrals, precertification, copayments, deductibles, and coinsurance.

ALTP agrees to assist the patient in obtaining maximum benefits from his/her insurance
company. However, ALTP is not obligated to withhold statements or to wait for insurance
payment on a patient account before receiving payment for our services.

ALTP reserves the right to utilize a collection agency in collecting on delinquent accounts. If a
collection service is utilized, I understand that I am responsible for any and all costs incurrent in
the collecting of my balance. This includes, but may not be limited to, attorney fees and a
collection fee of 30%. Any check that is returned for insufficient funds will result in a charge of
$25.00 for each occurrence.

I have been provided with an opportunity to review this documentation, and this is shown
through my signing of this consent/authorization.

Signature of Patient or Responsible Party

Today’s Date
 119 West H Ave., North Little Rock, Arkansas 72116
Phone 501-772-3224 · Fax 501-771-7648

Patient Attendance Policy

At Arkansas Lymphedema and Therapy Providers we strive to give every client an exceptional
and individualized experience. Our clients are seen one-on-one by a Lymphedema therapist. We
make every effort to stay on time and see you at your appointed times. We also make every
effort, as cancellations arise, to schedule clients who may be having serious complications due to
their edema. In order for us to provide optimal care to those who are currently being treated and
those who are awaiting treatment, we ask three things of you:

1) Please arrive 10-15 minutes prior to your scheduled appointment. This will allow for
the preparation time needed prior to your treatment. If work or other scheduling
conflicts make this difficult, please notify your therapist.

2) If you become aware of your inability to attend a scheduled appointment, a 24 hour

notice is requested. If we can reschedule you for another time that day, we will do so.
If not, you will be rescheduled at the earliest appointment time possible. It may also
be possible to have a shortened treatment time, addressing any critical needs.
A $40.00 fee will be charged for No Call/ No Show appointment.

3) If you become ill the day of your scheduled appointment, please call to cancel before
your appointment time. If you do not call and do not show for an accumulative of
three scheduled appointment, action will have to be taken.
a. Verbal counsel with your therapist will be performed discussing the need
for compliance.
b. If a fourth No Call/No Show occurs you will be removed from the
schedule, your physician will be contacted, and a new referral will be
required to return for continued therapy.

We understand that no one can predict what is dealt to us from day to day, but we ask that you
help us to make this experience a positive one for you, other patients, and our staff. We are very
excited to have you here and look forward to helping you in every way possible.
Patient Signature: ______________________________ Date: _________________________
 INTAKE QUESTIONNAIRE

Please circle all of the following diagnoses that apply to you: (please add any not listed)
Asthma Diabetes Kidney Disease/Renal Failure
Aortic/Abdominal Aneurysm Arterial Disease Cellulitis or Infections
COPD Heart Attack Arthritis
Congestive Heart Failure/CHF High Blood Pressure/HTN Rheumatoid Arthritis
Hernia Spinal Cord Injury Liver Disease
Diverticulitis Colitis Stroke/TIA
Cancer: ____________________ Osteoporosis Orthopedic problems_______________
Other: _____________________ Bipolar disorder Depression

Please list surgeries and dates (month & year if possible): (if you need more room, please use back of this page)
Circle any that apply:
Mastectomy _________________________ _________________________
Reconstruction _________________________ _________________________
Lumpectomy _________________________ _________________________
______________________________ _________________________ _________________________

Please list any known drug allergies: __No known allergies __LATEX allergy
Allergies: ___________________________________________________________________________________

Please supply a list of medications you currently take; please include supplements, herbs, vitamins, etc.
(we will make a copy of your printed list, if you have one; use back of page if needed)._______________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Please list any CHEMOTHERAPY you are currently on: _________________________________________________
_____________________________________________________________________________________________
Have you been hospitalized recently? YES NO
If YES: Where(which hospital):___________________________________ Date(s):_________________________
Reason:__________________________
Other info:___________________________________________________________________________________

Have you ever had CELLULITIS or an INFECTION in the limb that is swollen? YES NO
If yes, When/How long ago? ______________________________________________________________
If yes, Were you hospitalized? YES NO If yes, Where & for How long:__________________________

Have you had wounds/ulcers/sores on the swollen limb? YES NO

Do you have ANY wounds now? YES NO If yes, where?_____________________________________________

Have you been or are you being treated at a wound care facility or Clinic? YES NO
If yes, where?____________________________
1
Have you had “leaking” or “weeping” from the swollen limb? YES NO
Are you having leaking or weeping now? YES NO If yes, for how long____________________________
Are you currently taking a “water pill” or Diuretic for the swelling? YES NO
If yes, has the dosage been changed or increased recently? YES NO

Please circle any treatments you have received for your swelling, or have been directed to do for your swelling:
Elevation of swollen limb Exercise Surgery
Compression stockings/Sleeve Compression pump Antibiotics
Manual Lymphatic Drainage Compression bandaging PROFORE
Traditional massage Diuretics (“water pills”) Unaboot

Are you currently taking any of the following CHEMOTHERAPY medications: (please circle any that apply)
ZELODA DOXIL DOXYROBICIN ADRIAMYOSIN(“RED DEVIL”)
Did you take any of these in the past? If yes, please indicate that with a “P”

Functional Ability: (please check all that apply)

__I live alone __ I am fully independent in my daily activities.
__I live with a spouse/significant other __I am the caregiver for a spouse/family member
__I live in an Assisted Living or Independent Living Center __I live in a Nursing Home
__I require assistance with bathing/dressing:
who helps you with these things:_______________

Do you use any tobacco products? (circle any that apply) cigarettes chewing tobacco/dip e-cigarettes
How many/how often do you use these tobacco products? ____packs per day Other: ___________________

More
Nearly
Over the past 2 weeks, how often have you been bothered by any of the Not At Several Than
Every
following problems? All Days Half the
Day
Days
1. Little interest or pleasure in doing things 0 1 2 3
2. Feeling down, depressed 0 1 2 3
3. Trouble falling asleep, staying asleep, or sleeping too much 0 1 2 3
4. Feeling tired or having little energy 0 1 2 3
5. Poor appetite or overeating 0 1 2 3
6. Feeling bad about yourself – or that you’re a failure or have let
0 1 2 3
yourself or your family down
7. Trouble concentrating on things, such as reading the newspaper or
0 1 2 3
watching television
8. Moving or speaking so slowly that other people could have
noticed. Or, the opposite – being so fidgety or restless that you 0 1 2 3
have been moving around a lot more than usual
9. Thoughts that you would be better off dead or of hurting yourself
0 1 2 3
in some way

Continued on next page.

2
 1. Have you relied on people for any of the following: bathing, Did not
YES NO
dressing, shopping, banking, or meals? Answer
2. Has anyone prevented you from getting food, clothes, medication,
Did not
glasses, hearing aides, or medical care, or from being with people YES NO
Answer
you wanted to be with?
3. Have you been upset because someone talked to you in a way that Did not
YES NO
made you feel shamed or threatened? Answer
4. Has anyone tried to force you to sign papers or to use your money Did not
YES NO
against your will? Answer
5. Has anyone made you afraid, touched you in ways that you did not Did not
YES NO
want, or hurt you physically? Answer

Please add any other comments about your answers that you feel we need to know:
________________________________________________________________________________________________
________________________________________________________________________________________________

What is your goal for attending therapy (what do you want to accomplish)?_________________________________
________________________________________________________________________________________________

How did you hear about us? (check all that apply)
___ Doctor’s office: _________________________________
___ Physical or Occupational Therapist: ________________
___ Friend/relative who received treatment here.
___ OTHER: _______________________________________

3
 119 West H Ave., North Little Rock, Arkansas 72116
Phone 501-772-3224 · Fax 501-771-7648

SUMMARY OF NOTICE OF PRIVACY PRACTICES

This summary is provided to assist you in understanding
the attached Notice of Privacy Practices

The attached Notice of Privacy Practices contains a detailed description of how our office will protect your health information, your
rights as a patient and our common practices in dealing with patient health information. Please refer to that Notice for further
information.

 To the FDA to report product defects or incidents;

Uses and Disclosures of Health Information. We will use
and disclose your health information in order to treat you or to
 To law enforcement authorities to protect public
safety or to assist in apprehending criminal offenders;
assist other health care providers in treating you. We will also
use and disclose your health information in order to obtain  When required by court orders, search warrants,
payment for our services or to allow insurance companies to subpoenas and as otherwise required by the law.
process insurance claims for services rendered to you by us or
other health care providers. Finally, we may disclose your
health information for certain limited operational activities
such as quality assessment, licensing, accreditation and
training of students.

Uses and Disclosures Based on Your Authorization. Patient Rights. As our patient, you have the following rights:
Except as stated in more detail in the Notice of Privacy  To have access to and/or a copy of your health
Practices, we will not use or disclose your health information information;
without your written authorization.  To receive an accounting of certain disclosures we
have made of your health information;
Uses and Disclosures Not Requiring Your Authorization.
In the following circumstances, we may disclose your health  To request restrictions as to how your health
information without your written authorization: information is used or disclosed;
 To family members or close friends who are  To request that we communicate with you in
involved in your health care; confidence;
 For certain limited research purposes;  To request that we amend your health information;
 For purposes of public health and safety;  To receive notice of our privacy practices.
 To Government agencies for purposes of their audits, If you have a question, concern or complaint regarding our
investigations and other oversight activities; privacy practices, please refer to the attached Notice of
 To government authorities to prevent child abuse or Privacy Practices for the person or persons whom you may
domestic violence; contact.

ALTP Privacy 2/21/14

 NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND
HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW IT CAREFULLY. THE PRIVACY OF YOUR MEDICAL INFORMATION IS IMPORTANT TO US.

Our Legal Duty

We are required by applicable federal and state laws to reserve the right to make the changes in our privacy practices
maintain the privacy of your protected health information. We and the new terms of our notice effective for all protected
are also required to give you this notice about our privacy health information that we maintain, including medical
practices, our legal duties, and your rights concerning your information we created or received before we made the
protected health information. We must follow the privacy changes. You may request a copy of our notice (or any
practices that are described in this notice while it is in effect. subsequent revised notice) at any time. For more information
This notice takes effect April 14, 2003, and will remain in about our privacy practices, or for additional copies of this
effect until we replace it. We reserve the right to change our notice, please contact us using the information listed at the end
privacy practices and the terms of this notice at any time, of this notice.
provided that applicable law permits such changes. We

Uses and Disclosures of Protected Health Information

We will use and disclose your protected health information

about you for treatment, payment, and health care operations. Health Care Operations: We may use or disclose, as needed,
Following are examples of the types of uses and disclosures of your protected health information in order to conduct certain
your protected health care information that may occur. These business and operational activities. These activities include,
examples are not meant to be exhaustive, but to describe the but are not limited to, quality assessment activities, employee
types of uses and disclosures that may be made by our office. review activities, training of students, licensing, and
conducting or arranging for other business activities. For
Treatment: We will use and disclose your protected health example, we may use a sign-in sheet at the registration desk
information to provide, coordinate or manage your health care where you will be asked to sign your name. We may also call
and any related services. This includes the coordination or you by name in the waiting room when your doctor is ready to
management of your health care with a third party. For see you. We may use or disclose your protected health
example, we would disclose your protected health information, as necessary, to contact you by telephone or mail
information, as necessary, to a home health agency that to remind you of your appointment.
provides care to you. We will also disclose protected health
information to other physicians who may be treating you. For We will share your protected health information with third
example, your protected health information may be provided party “business associates” that perform various activities
to a physician to whom you have been referred to ensure that (e.g., billing, transcription services) for the practice. Whenever
the physician has the necessary information to diagnose or an arrangement between our office and a business associate
treat you. In addition, we may disclose your protected health involves the use or disclosure of your protected health
information from time to time to another physician or health information, we will have a written contract that contains
care provider (e.g., a specialist or laboratory) who, at the terms that will protect the privacy of your protected health
request of your physician, becomes involved in your care by information. We may use or disclose your protected health
providing assistance with your health care diagnosis or information, as necessary, to provide you with information
treatment to your physician. about treatment alternatives or other health-related benefits
and services that may be of interest to you. We may also use
Payment: Your protected health information will be used, as and disclose your protected health information for other
needed, to obtain payment for your health care services. This marketing activities. For example, your name and address may
may include certain activities that your health insurance plan be used to send you a newsletter about our practice and the
may undertake before it approves or pays for the health care services we offer. We may also send you information about
services we recommend for you, such as: making a products or services that we believe may be beneficial to you.
determination of eligibility or coverage for insurance benefits, You may contact us to request that these materials not be sent
reviewing services provided to you for protected health to you.
necessity, and undertaking utilization review activities. For
example, obtaining approval for a hospital stay may require Uses and Disclosures Based On Your Written
that your relevant protected health information be disclosed to Authorization: Other uses and disclosures of your protected
the health plan to obtain approval for the hospital admission. health information will be made only with your authorization,
 119 West H Ave., North Little Rock, Arkansas 72116
Phone 501-772-3224 · Fax 501-771-7648

unless otherwise permitted or required by law as described Health Oversight: We may disclose protected health
below. You may give us written authorization to use your information to a health oversight agency for activities
protected health information or to disclose it to anyone for any authorized by law, such as audits, investigations and
purpose. If you give us an authorization, you may revoke it in inspections. Oversight agencies seeking this information
writing at any time. Your revocation will not affect any use or include government agencies that oversee the health care
disclosures permitted by your authorization while it was in system, government benefit programs, other government
effect. Without your written authorization, we will not regulatory programs and civil rights laws.
disclose your health care information except as described in
this notice. Abuse or Neglect: We may disclose your protected health
information to a public health authority that is authorized by
Others Involved in Your Health Care: Unless you object, law to receive reports of child abuse or neglect. In addition,
we may disclose to a member of your family, a relative, a we may disclose your protected health information if we
close friend or any other person you identify, your protected believe that you have been a victim of abuse, neglect or
health information that directly relates to that person’s domestic violence to the governmental entity or agency
involvement in your health care. If you are unable to agree or authorized to receive such information. In this case, the
object to such a disclosure, we may disclose such information disclosure will be made consistent with the requirements of
as necessary if we determine that it is in your best interest applicable federal and state laws.
based on our professional judgment. We may use or disclose
protected health information to notify or assist in notifying a Food and Drug Administration: We may disclose your
family member, personal representative or any other person protected health information to a person or company required
that is responsible for your care of your location, general by the Food and Drug Administration to report adverse events,
condition or death. product defects or problems, biologic product deviations; to
track products; to enable product recalls; to make repairs or
Marketing: We may use your protected health information to replacements; or to conduct post marketing surveillance, as
contact you with information about treatment alternatives that required.
may be of interest to you. We may disclose your protected
health information to a business associate to assist us in these Criminal Activity: Consistent with applicable federal and
activities. Unless the information is provided to you by a state laws, we may disclose your protected health information,
general newsletter or in person or is for products or services of if we believe that the use or disclosure is necessary to prevent
nominal value, you may opt out of receiving further such or lessen a serious and imminent threat to the health or safety
information by telling us using the contact information listed of a person or the public. We may also disclose protected
at the end of this notice. health information if it is necessary for law enforcement
authorities to identify or apprehend an individual.
Research; Death; Organ Donation: We may use or disclose
your protected health information for research purposes in Required by Law: We may use or disclose your protected
limited circumstances. We may disclose the protected health health information when we are required to do so by law. For
information of a deceased person to a coroner, protected example, we must disclose your protected health information
health examiner, funeral director or organ procurement to the U.S. Department of Health and Human Services upon
organization for certain purposes. request for purposes of determining whether we are in
compliance with federal privacy laws. We may disclose your
Public Health and Safety: We may disclose your protected protected health information when authorized by workers’
health information to the extent necessary to avert a serious compensation or similar laws.
and imminent threat to your health or safety, or the health or
safety of others. We may disclose your protected health Process and Proceedings: We may disclose your protected
information to a government agency authorized to oversee the health information in response to a court or administrative
health care system or government programs or its contractors, order, subpoena, discovery request or other lawful process,
and to public health authorities for public health purposes. under certain circumstances. Under limited circumstances,
such as a court order, warrant or grand jury subpoena, we may

ALTP Privacy 2/21/14

disclose your protected health information to law enforcement custody to a law enforcement official or correctional
officials. institution under certain circumstances. We may disclose
protected health information where necessary to assist law
Law Enforcement: We may disclose limited information to a enforcement officials to capture an individual who has
law enforcement official concerning the protected health admitted to participation in a crime or has escaped from lawful
information of a suspect, fugitive, material witness, crime custody.
victim or missing person. We may disclose the protected
health information of an inmate or other person in lawful

Patient Rights

Access: You have the right to look at or get copies of your these additional restrictions, but if we do, we will abide by our
protected health information, with limited exceptions. You agreement (except in an emergency). Any agreement we may
must make a request in writing to the contact person listed make to a request for additional restrictions must be in writing
herein to obtain access to your protected health information. signed by a person authorized to make such an agreement on
You may also request access by sending us a letter to the our behalf. We will not be bound unless our agreement is so
address at the end of this notice. If you request copies, we will memorialized in writing.
charge you $___ for each page, $___ per hour for staff time to
locate and copy your protected health information, and Confidential Communication: You have the right to request
postage if you want the copies mailed to you. If you prefer, we that we communicate with you in confidence about your
will prepare a summary or an explanation of your protected protected health information by alternative means or to an
health information for a fee. Contact us using the information alternative location. You must make your request in writing.
listed at the end of this notice for a full explanation of our fee We must accommodate your request if it is reasonable,
structure. specifies the alternative means or location, and continues to
permit us to bill and collect payment from you.
Accounting of Disclosures: You have the right to receive a Amendment: You have the right to request that we amend
list of instances in which our business associates or we your protected health information. Your request must be in
disclosed your protected health information for purposes other writing, and it must explain why the information should be
than treatment, payment, health care operations and certain amended. We may deny your request if we did not create the
other activities after April 14, 2003. After April 14, 2009, the information you want amended or for certain other reasons. If
accounting will be provided for the past six (6) years. We will we deny your request, we will provide you a written
provide you with the date on which we made the disclosure, explanation. You may respond with a statement of
the name of the person or entity to whom we disclosed your disagreement to be appended to the information you wanted
protected health information, a description of the protected amended. If we accept your request to amend the information,
health information we disclosed, the reason for the disclosure, we will make reasonable efforts to inform others, including
and certain other information. If you request this list more people or entities you name, of the amendment and to include
than once in a 12-month period, we may charge you a the changes in any future disclosures of that information.
reasonable, cost-based fee for responding to these additional
requests. Contact us using the information listed at the end of Electronic Notice: If you receive this notice on our website
this notice for a full explanation of our fee structure. or by electronic mail (e-mail), you are entitled to receive this
notice in written form. Please contact us using the information
Restriction Requests: You have the right to request that we listed at the end of this notice to obtain this notice in written
place additional restrictions on our use or disclosure of your form.
protected health information. We are not required to agree to
Questions and Complaints:

If you want more information about our privacy practices or Services upon request. We support your right to protect the
have questions or concerns, please contact us using the privacy of your protected health information. We will not
information below. If you believe that we may have violated retaliate in any way if you choose to file a complaint with us
your privacy rights, or you disagree with a decision we made or with the U.S. Department of Health and Human Services.
about access to your protected health information or in
response to a request you made, you may complain to us using Name of Contact Person:
the contact information below. You also may submit a written TROY or STACY ALBERSON
complaint to the U.S. Department of Health and Human Telephone: 501-772-3224; Fax: 501-771-7648
Services. We will provide you with the address to file your [email protected]
complaint with the U.S. Department of Health and Human 119 West H Ave ·North Little Rock, Arkansas 72116
 119 West H Ave., North Little Rock, Arkansas 72116
Phone 501-772-3224 · Fax 501-771-7648

ACKNOWLEDGMENT OF RECEIPT

OF NOTICE OF PRIVACY PRACTICES

I acknowledge that I was provided a copy of the Notice of Privacy Practices and that I have read (or had the opportunity to read if I so
chose) and understood the Notice.

_________________________________________ ______________________________________
Signature Date

_________________________________________
Patient Name (please print)