Acknowledgement of Receipt of Notice of Privacy Practices

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Associates in Gastroenterology, PC reserves the right to modify the privacy practices outlined in the notice.

I have read or received a copy of the Privacy Practices for: Associates in Gastroenterology, P.C.

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Required if a patient is a minor or adult unable to sign this form

List persons you give Associates in Gastroenterology, PC staff authorization to discuss your medical records with, other than yourself.

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