Acknowledgement

METROPLEX PULMONARY & SLEEP CENTER, P.A
4833 Medical Center Drive, Suite 6B McKinney, Texas 75069
Phone: 972- 838-1892 Fax: 972-838-1896 or 972-954-6030
ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
Patient Name:*
Date of Birth:*
Social Security Number:*
I acknowledge that Metroplex Pulmonary and Sleep Center provided me with a written copy its Notice of Privacy Practices.

I also acknowledge that I have been afforded the opportunity to read the Notice of Privacy Practices and ask questions.
Patient Signature*
Date*
MM slash DD slash YYYY
Personal Representative Signature (if applicable)
Relationship to Patient
Sleep and breathing disorders are extremely common in this country and affect daytime wakefulness to different degree in each person. Obviously, each person must use his or her best judgement to be safe during operating heavy machinery, behind the wheel or working at heights. Furthermore, you should also be aware that sleep medications may cause daytime drowsiness as well. Therefore, you should not expose yourself to others to avoid possible harm due to potential drowsiness.
For your protection we require that you have received this notice. Therefore, please sign below.
Signature of Patient:*
Date*
MM slash DD slash YYYY