PACIFIC SLEEP CENTER, PLLC
NOTICE OF PRIVACY PRACTICES —ACKNOWLEDGEMENT Last Update:04/01/06
We keep a record of the health care services we provide you. You may ask to see and copy that record. You may
also ask to correct that record. We will not disclose your record to others unless you direct us to do so or unless the
law authorizes or compels us to do so. You may see your record or get more information about it by contacting the
Administrator at (425)670-9097.
Our Notice of Privacy Practices describes in more detail how your health information may be used and disclosed,
and how you can access your information.
By my signature below I acknowledge I have accessed and read the Notice of Privacy Practices on www.pacsleep.
com.
_________________________________________________ ______________________________
*SIGNATURE of patient or legally authorized individual Date
_________________________________________________ _______________________________
Printed name if signed on behalf of the patient Relationship
(parent, legal guardian, personal representative)
This form will be retained in your medical record.
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