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Yuma Pediatrics LTD 2359 22nd Drive, Suite 2, Yuma, AZ 853648865 Tel. 9283444800 Fax 9287262377 www.yumapediatrics.com ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES Federal H IPA A law

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How to fill out yuma pediatrics ltd acknowledgement

01

Start by reading the acknowledgement form provided by Yuma Pediatrics Ltd.

02

Fill in your personal information accurately, including your full name, address, phone number, and date of birth.

03

If applicable, provide the name of your child and their date of birth.

04

Read the terms and conditions carefully and make sure you understand them.

05

Sign and date the acknowledgement form at the designated areas.

06

Review the completed form to ensure all information is correct and legible.

07

Return the filled out form to Yuma Pediatrics Ltd. as specified.

Who needs yuma pediatrics ltd acknowledgement?

01

Anyone who is a patient or parent/legal guardian of a patient at Yuma Pediatrics Ltd. needs to fill out the acknowledgement form.

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