Medical Arts Building
1169 Eastern Parkway, Suite 2243
Louisville, KY 40217
Phone: (502) 452-9227
Fax: (502) 452-1529
Acknowledgement of Receipt
Stuecker & Associates
Inc.
NOTICE OF PRIVACY PRACTICES
By signing this page you acknowledge that you have received a copy of our Notice of Privacy Practices.
Patient Name: ____________________________________________________________
Signature of Patient or Personal Representative: ______________________________
Print Name of Personal Representative (if not patient): ________________________
Date Signed: ____________________________________________________________
Witnessed by: ____________________________________________________________