Acknowledgement of Receipt of Notice of Privacy Practices

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.

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.

Name of Patient

Signature of Patient

Date

Signature of Patient Representative

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

Relationship of Representative

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

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