Fuad Afzal, MD
P.O.Box 952951
Lake Mary, FL 32795
Phone: 407-896-1789 Fax: 407-896-1735
www.midfloridakidney.com

Acknowledgement of Receipt of Notice of Privacy Practices

I, ________________________________________, have received the Notice of privacy Practices from Mid-Florida

Kidney and Hypertension Care.

 

X____________________________________ Date:_____________________________

 

 

In the event patient refuses or is not able to sign, staff member will complete below.

In lieu of patient signature, I, ______________________________, a staff member of Mid-Florida Kidney and

Hypertension Care, state that____________________________ has been given our current Notices of Privacy

Practices.

 

X____________________________________ Date:_____________________________

 

If you need immediate assistance or have further questions, please call us at the number above.