NOTICE OF PRIVACY PRACTICES

Date:

By signing this form, you acknowledge receipt of the Notice of Privacy Practices from Prime Care of Coral Gables. The Notice of Privacy Practices provides information about how we may use and disclose your protected health information. We encourage you to review it carefully.

I acknowledge that I was provided with a copy of the PrimeHealthPhysicians, LLC Notice of Privacy Practices.

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

Patient Name:

Patient Signature:

If completed by a patient's personal representative, please print and sign your name in the space below

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

Personal Representative:

Personal Representative's Signature:

Relationship:

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