HIPPA Privacy Form​

You will need to submit the HIPAA privacy policy acknowledgement
form below.

Download Forms

If you prefer, you may download the forms here as pdf’s and fax them to 617.232.8580 ahead of your appointment time.
New Patient Form
Hippa Privacy Form

HIPPA Privacy Form​​

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES


The privacy of your protected health information is important to us. We have offered to provide you with a copy of our Notice of Privacy Practices. It describes how your health information will be handled in various situations. We ask that you sign this form to acknowledge you have been offered a copy of our Notice of Privacy Practices. This includes the situation where your first date of service occurred electronically.

If your first date of service with us was due to an emergency, we will try to give you this notice and get your signature acknowledging receipt of this notice as soon as we can after the emergency.

I have been offered the Privacy Notice of Daniel Mollod, M.D.

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