Acknowledgement of Receipt of Notice of Privacy Practices

Please correct the errors described below.

I acknowledge that I was provided a copy of the Notice of Privacy Practices and that I have read (or had the opportunity to read ifI so chose) and understood the Notice.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

If applicable only for caregivers, guardians, or anyone who will be present in exam room)

to be in the exam room during my treatments, participate in my care or have access to my records

Your information will be encrypted.

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