{"id":1626,"date":"2023-08-14T00:07:21","date_gmt":"2023-08-14T00:07:21","guid":{"rendered":"https:\/\/starchoicepediatrics.com\/?page_id=1626"},"modified":"2023-08-14T00:08:32","modified_gmt":"2023-08-14T00:08:32","slug":"privacy-form","status":"publish","type":"page","link":"https:\/\/starchoicepediatrics.com\/?page_id=1626","title":{"rendered":"Privacy Form"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"1626\" class=\"elementor elementor-1626\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-b80cbd7 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"b80cbd7\" data-element_type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-be9bca4\" data-id=\"be9bca4\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-cf7704d elementor-widget elementor-widget-shortcode\" data-id=\"cf7704d\" data-element_type=\"widget\" data-widget_type=\"shortcode.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-shortcode\"><div class=\"forminator-ui forminator-custom-form forminator-custom-form-1625 forminator-design--flat  forminator_ajax\" data-forminator-render=\"0\" data-form=\"forminator-module-1625\" data-uid=\"69e17ff23868d\"><br\/><\/div><form\n\t\t\t\tid=\"forminator-module-1625\"\n\t\t\t\tclass=\"forminator-ui forminator-custom-form forminator-custom-form-1625 forminator-design--flat  forminator_ajax\"\n\t\t\t\tmethod=\"post\"\n\t\t\t\tdata-forminator-render=\"0\"\n\t\t\t\tdata-form-id=\"1625\"\n\t\t\t\t\n\t\t\t\tdata-design=\"flat\"\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\tdata-grid=\"open\"\n\t\t\t\t\n\t\t\t\t\n\t\t\t\tstyle=\"display: none;\"\n\t\t\t\t\n\t\t\t\tdata-uid=\"69e17ff23868d\"\n\t\t\t><div role=\"alert\" aria-live=\"polite\" class=\"forminator-response-message forminator-error\" aria-hidden=\"true\"><\/div><div class=\"forminator-row\"><div id=\"section-1\" class=\"forminator-field-section forminator-col forminator-col-12 \"><div class=\"forminator-field\"><h2 class=\"forminator-title\">NOTICE OF PRIVACY PRACTICES PATIENT ACKNOWLEDGMENT<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"name-1\" class=\"forminator-field-name forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-1_69e17ff23868d\" id=\"forminator-field-name-1_69e17ff23868d-label\" class=\"forminator-label\">Patient Name <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"name-1\" value=\"\" placeholder=\"E.g. John\" id=\"forminator-field-name-1_69e17ff23868d\" class=\"forminator-input forminator-name--field\" aria-required=\"true\" \/><\/div><\/div><div id=\"date-1\" class=\"forminator-field-date forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-1-picker_69e17ff23868d\" id=\"forminator-field-date-1-picker_69e17ff23868d-label\" class=\"forminator-label\">Date Of BIrth<\/label><div class=\"forminator-input-with-icon\"><label for=\"forminator-field-date-1-picker_69e17ff23868d\"><span class=\"forminator-icon-calendar\" aria-hidden=\"true\"><\/span><\/label><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-1\" value=\"\" placeholder=\"Choose Date\" id=\"forminator-field-date-1-picker_69e17ff23868d\" class=\"forminator-input forminator-datepicker\" data-required=\"\" data-format=\"mm\/dd\/yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1926\" data-end-year=\"2126\" data-past-dates=\"enable\" data-start-of-week=\"1\" data-start-date=\"\" data-end-date=\"\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"html-1\" class=\"forminator-field-html forminator-col forminator-col-12 \"><div class=\"forminator-field forminator-merge-tags\" data-field=\"html-1\"><p>I have received this practice's Notice of Privacy Practice written in plain language. The Notice provides in detail uses and disclosures of my protected health information that may be made by this practice, my individual rights, how I may exercise these rights, and the practice's legal duties with respect to my information.<br>I understand that this practice reserves the right to change the terms of its Notice of Privacy Practices, and to make changes regarding all protected health information resident at, or controlled by, this practice. I understand and have obtained this practice's current Notice of Privacy Practices.<\/p><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-1\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-1_69e17ff23868d\" id=\"forminator-field-text-1_69e17ff23868d-label\" class=\"forminator-label\">Signature<\/label><input type=\"text\" name=\"text-1\" value=\"\" placeholder=\"Write your name\" id=\"forminator-field-text-1_69e17ff23868d\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><div id=\"date-2\" class=\"forminator-field-date forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-2-picker_69e17ff23868d\" id=\"forminator-field-date-2-picker_69e17ff23868d-label\" class=\"forminator-label\">Date<\/label><div class=\"forminator-input-with-icon\"><label for=\"forminator-field-date-2-picker_69e17ff23868d\"><span class=\"forminator-icon-calendar\" aria-hidden=\"true\"><\/span><\/label><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-2\" value=\"\" placeholder=\"Choose Date\" id=\"forminator-field-date-2-picker_69e17ff23868d\" class=\"forminator-input forminator-datepicker\" data-required=\"\" data-format=\"mm\/dd\/yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1926\" data-end-year=\"2126\" data-past-dates=\"enable\" data-start-of-week=\"1\" data-start-date=\"\" data-end-date=\"\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-2\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-2_69e17ff23868d\" id=\"forminator-field-text-2_69e17ff23868d-label\" class=\"forminator-label\">Relationship to the patient ( if signed by personal representative of patient )<\/label><input type=\"text\" name=\"text-2\" value=\"\" placeholder=\"\" id=\"forminator-field-text-2_69e17ff23868d\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><input type=\"hidden\" name=\"referer_url\" value=\"\" \/><div class=\"forminator-row forminator-row-last\"><div class=\"forminator-col\"><div class=\"forminator-field\"><button class=\"forminator-button forminator-button-submit\">Send Message<\/button><\/div><\/div><\/div><input type=\"hidden\" id=\"forminator_nonce\" name=\"forminator_nonce\" value=\"769c1d1375\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/index.php?rest_route=%2Fwp%2Fv2%2Fpages%2F1626\" \/><input type=\"hidden\" name=\"form_id\" value=\"1625\"><input type=\"hidden\" name=\"page_id\" value=\"1626\"><input type=\"hidden\" name=\"form_type\" value=\"default\"><input type=\"hidden\" name=\"current_url\" value=\"https:\/\/starchoicepediatrics.com\/?page_id=1626\"><input type=\"hidden\" name=\"render_id\" value=\"0\"><input type=\"hidden\" name=\"action\" value=\"forminator_submit_form_custom-forms\"><\/form><\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"om_disable_all_campaigns":false,"site-sidebar-layout":"no-sidebar","site-content-layout":"page-builder","ast-site-content-layout":"default","site-content-style":"default","site-sidebar-style":"default","ast-global-header-display":"","ast-banner-title-visibility":"","ast-main-header-display":"","ast-hfb-above-header-display":"","ast-hfb-below-header-display":"","ast-hfb-mobile-header-display":"","site-post-title":"disabled","ast-breadcrumbs-content":"","ast-featured-img":"disabled","footer-sml-layout":"","theme-transparent-header-meta":"","adv-header-id-meta":"","stick-header-meta":"","header-above-stick-meta":"","header-main-stick-meta":"","header-below-stick-meta":"","astra-migrate-meta-layouts":"default","ast-page-background-enabled":"default","ast-page-background-meta":{"desktop":{"background-color":"var(--ast-global-color-4)","background-image":"","background-repeat":"repeat","background-position":"center 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