I have reviewed this office's Notice of Privacy Practices, which explains how my medical information will be used and disclosed. I understand that I am entitled to receive a copy of this document.
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.
I allow the release of medical information to the following: (Please check all that apply)
I have read and understand this office policy and agree to comply and accept the responsibility for any payment that becomes due as outlined previously.
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.
Your information will be encrypted.