HIPAA
Notice of Privacy Policies
Last Name:
First Name:
Birthdate:
Date: 4/15/2024
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.
Signature will be recorded later.