Birthdate:Date: 7/13/2024First Name:Notice of Privacy PoliciesLast Name:
Signature will be recorded later.
I have had full opportunity to read and consider the contents of the Notice of Privacy Practices. I understand that I am giving my permission to your use and disclosure of my protected health information in order to carry out treatment, payment activities, and healthcare operations. I also understand that I have the right to revoke permission.