Release of Information Authorization Form

Please correct the errors described below.

Acknowledgment of Receipt of Notice of Privacy Practices

This signed form acknowledges that you have received a copy of our practice’s Notice of Privacy Practices as required by Federal Law. By signing below you are acknowledging that you understand and have read this notice. This notice is yours to keep.

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.

With whom may we discuss patient's information? (For patients over age 18)

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