HIPPA Privacy Form Name* Signature* Reset signature Signature locked. Reset to sign again Printed Name* Date* MM slash DD slash YYYY Staff Initials Could Not Be Obtained Because:Individual refused to sign Individual refused to sign Communication barrier Communication barrier prohibited obtaining the acknowledgement Emergency situation An emergency situation prevented us from obtaining acknowledgement Other Other Other (please specify) Δ
Aspen Dermatology & AestheticsAspen Dermatology & Aesthetics