California Pharmacy & Compounding Center
4000 Birch Street #120
Newport Beach, CA 92660
949-642-8057 800-575-7776 fax 949-642-0725
www.californiapharmacy.com

Acknowledgement of Receipt of the Notice of Privacy Practices

By signing this form, I acknowledge the receipt of the Pharmacy's "Notice of Privacy Practices" (Notice), which contains description of the uses and disclosures of protected health information that may be made by the Pharmacy, and of my rights, and the Pharmacy's responsibilities, with respect to protected health information. I have read and understand my rights under the Notice. I also understand the Notice is subject to change and I can request a current written Notice at anytime.

The Pharmacy is required to obtain my written authorization before using or disclosing my personal health information for purposes other than those provided for in the Notice or as otherwise permitted or required by law. I understand that I have the right to revoke this authorization in writing, except to the extent that the pharmacy has relied on it.

My signature below signifies I have read and understand the Notice.

Please return via mail or fax to the address/fax number above.

Thank you.