Receipt of Notice of Privacy Practices

I, [Enter Name Below] Have been notified that upon my request, I will receive a copy of Moorestown Dermatology Associates Notice of Privacy Practices

PLEASE INDICATE THE PHONE NUMBERS WHERE MESSAGES CAN BE LEFT.

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PLEASE IDENTIFY THOSE PEOPLE YOU WISH TO HAVE ACCESS TO YOUR PROTECTED HEALTH INFORMATION:

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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.

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