Privacy Share Form

ALTERNATE COMMUNICATION REQUEST FORM

Receipt of Notice of Privacy Practices 

I wish to be contacted in the following manner (check all that apply):

By the home cell or work phone listed on my registration form

I give permission to the following individual(s) to obtain the indicated information on my behalf 

It is the responsibility of the patient to notify this office if there is a change in this information 

By submitting this form, I release the doctor and staff therein, from liability for release of information pertaining to my care as designated above.  I further acknowledge that I have received a copy of the doctor’s Notice of Privacy Practices (Effective date of the notice: 01/01/2010.) 

Terry L. Henderson, DC | Douglas P. Krift, DC | Philip A. Ryan IV, DC

1467 South Fort Thomas Ave.
Fort Thomas, KY 41075