HOWARD  TUNG, M.D.
NEUROSURGERY
PRACTICE LIMITED TO SPINAL AND BRAIN DISORDERS
DIPLOMATE  AMERICAN  BOARD  OF  NEUROLOGICAL  SURGERY 

							
Acknowledge of Receipt of Notice of Privacy 
And Consent Form

This is to acknowledge that if I so request, I will receive a copy of the Notice of Privacy Practices for La Jolla Orthopedic, Inc., Dr. Howard Tung, in accordance with the requirements of the Health Insurance Portability and Accountability Act of 1995 (HIPAA). I consent to Dr. Howard Tung’s use and disclosure of my “protected health information”, as defined by HIPAA, for treatment, payment, and health care operations.

(Patient’s Name-PRINTED)

(Signature of Patient/Parent/Legal Guardian)

(Relationship of Person Who Signed for the Patient)

_________________________________
 (Date Signed)