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Privacy practices

Acknowledge our Notice of Privacy Practices and tell us who may receive your medical information.

  • About 2 minutes
  • Sent securely to our office; not saved on this website
  • Every new patient

Online sending isn’t switched on yet

You can look through the forms, but they can’t be sent from this website yet. Please complete them at your visit, or call (818) 859-7730.

  1. Notice of Privacy Practices
  2. Review & send

Notice of Privacy Practices

I have reviewed the Notice of Privacy Practices. I acknowledge that I may request a copy of the Notice of Privacy Practices for Burbank Audiology Center.

Read our Notice of Privacy Practices (opens in a new tab, so your answers stay here)

You may release medical information to:
Would you like a copy of the Notice of Privacy Practices? (required)
Who is filling out this form? (required)

I agree to sign this form electronically. Typing my name below is my signature, with the same effect as signing the paper form.

Draw your signature (optional)

Use your finger, a stylus or a mouse. If you skip this, your typed name is used as your signature.

Review & send

Please check your answers. Use “Edit” to change anything before you send.

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