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Patient Forms · Privacy & records

Acknowledgment of Notice of Privacy Practices

Confirm that you were given, or offered, our Notice of Privacy Practices (opens in a new tab) — about 1 minute. It is also part of the New Patient Packet (opens in a new tab).

Send it online when you finish, or print it and bring it to your visit. What you send goes securely to our office’s patient system. Nothing is sent until you press Send, and nothing you type is saved on this device.

Start Print a blank copy (opens in a new tab)

Urological Consultants of Florida
12411 Biscayne Boulevard, North Miami, FL 33181 · (305) 672-4222 · www.miamiurologyconsultants.com

Acknowledgment of Notice of Privacy PracticesNPP-ACK-1 · v2026.11.2

Acknowledgment of Notice of Privacy Practices

About 1 minutes · NPP-ACK-1 · v2026.11.2

All fields are required unless marked (optional).

About the patient

MM/DD/YYYY

Notice of Privacy Practices

Read our Notice of Privacy Practices (opens in a new tab), or the one-page summary (opens in a new tab), before you sign.

Acknowledgment of Receipt of Notice of Privacy Practices

I acknowledge that I was given, or offered, a copy of the Notice of Privacy Practices of Urological Consultants of Florida, effective November 15, 2026. The Notice explains how my health information may be used and shared, and describes my rights, including my right to see and get a copy of my records, to ask for corrections, to ask for limits on how my information is used, to be told if my unsecured health information is breached, and to complain without being penalized.

I understand that the practice may change its Notice, and that the current version is available at the front desk and at www.miamiurologyconsultants.com/notice-of-privacy-practices.html.

Signing this form does not mean I agree to anything beyond receiving the Notice. My treatment does not depend on whether I sign it.

Questions about your privacy rights? Ask for our Privacy Officer, Tania Espinoza, at (305) 672-4222.

Who is signing?

Signature of patient or personal representative

For office use only

If the patient did not sign, record the good-faith effort made and the reason:

  • Patient declined to sign
  • Emergency treatment; acknowledgment to be sought later
  • Patient unable to sign
  • Notice provided electronically (e-mail / portal) on ____________
  • Other: ______________________________
Staff member (print and initial)
Date

Review and send

When you have finished, send your answers to our office. Nothing is sent until you press Send to the practice. You can also print your form and bring it instead.

Sent securely to our office’s patient system. This page does not save what you type on this device.

What to bring to your visit

  • Photo ID
  • Your insurance card(s)
  • Your medication list or bottles
  • Any referral or recent records, if you have them

Questions? Call (305) 672-4222, Monday–Friday, 9:00 am – 5:00 pm.