Burbank Compounding Pharmacy
201 S. Buena Vista St. Suite 110
Burbank, CA 91505
(818) 563-2120 Tel
(818) 563-2130 Fax
Acknowledgement of Receipt of the Notice of Privacy
Practices
By signing this form, I acknowledge the receipt of the
Pharmacy's "Notice of Privacy Practices" (Notice), which contains description of
the uses and disclosures of protected health information that may be made by the
Pharmacy, and of my rights, and the Pharmacy's responsibilities, with respect to
protected health information. I have read and understand my rights under the
Notice. I also understand the Notice is subject to change and I can request a
current written Notice at anytime.
The Pharmacy is required to obtain my written authorization
before using or disclosing my personal health information for purposes other
than those provided for in the Notice or as otherwise permitted or required by
law. I understand that I have the right to revoke this authorization in writing,
except to the extent that the pharmacy has relied on it.
My signature below signifies I have read and understand the
Notice.
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Please return via mail or fax to the address/fax number
above.
Thank you.
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