NIRSCHL ORTHOPAEDIC CENTER

                         FOR SPORTS MEDICINE AND JOINT RECONSTRUCTION                                                                             

     1715 N George Mason Drive, Suite 504, Arlington, Va. 22205        Fax: (703) 522-2603

        

  Robert P. Nirschl, M.D., M.S.                                           William C.Lennen, M.D.

    (703 525-2200                                                                          (703) 525-5518

 

  Eric J. Guidi, M.D.                                                              Patrick St. Pierre, M.D.

    (703) 841-0551                                                                        (703) 894-1123

 

   Derek Ochiai, M.D.

    (703) 525-8183    

 

PATIENT ACKNOWLEDGMENT OF RECEIPT OF PRIVACY NOTICE

 

 

Patients Name:____________________________________

 

I acknowledge receipt of the Notice of Privacy Practices given to me by Nirschl Orthopaedic

Center for Sports Medicine and Joint Reconstruction.

 

 

___________________________________________________  Date_________________

Signature of Patient or Legal Representative

 

If Signed by Representative, Relationship to Patient:_________________________________