HIPAA
Last Name
Last Name is a required field
First Name
First Name is a required field
Invalid Date of Birth. Format MM/dd/yyyy
Birthdate
Birthdate is a required field
Date 12/26/2024
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.