Last Name
First Name
Date 10/20/2021
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. (A copy of the Notice of Privacy Practices is available on our website - https//www.doctorcowman.com/)