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Receipt of Notice of Privacy Practices Written Acknowledgement Form

You may fill out and submit this form on our Web site! Or, if you have concerns about providing information via the Internet, fill it out, and print it prior to an appointment. Then bring it with you to your first visit to save time when you arrive.

**You May Refuse to Sign or Send This Acknowledgement**

I, , have received a copy of Stacey M. Johnson, MD, PA's Notice or Privacy Practices that appears on this Web site.


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You may fill out and submit this form on our Web site! Or, if you have concerns about providing information via the Internet, fill it out, and print it prior to an appointment. Then bring it with you to your first visit to save time when you arrive.
Stacey M. Johnson, M.D.

Physicians' Medical Center of the Ozarks · 17 Medical Plaza · Mountain Home, AR 72653
Toll-Free 1-866-749-7633 · (870) 425-6212 · Fax (870) 424-3774 · www.physmedcenter.com

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http://www.physmedcenter.com
01/22/2008

Services About Physician's Medical Center Physicians and Staff Patient Care News and Events Resources Facility Patient Testimonials Patient Education View Videos Online Patient Education Contact Us Home Location / Maps Site Map View Videos Online MD Articles and Publications