Privacy Practices

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ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

I, acknowledge that Advanced Allergy & Asthma Associates has provided me a copy of their Notice of Privacy Practices, effective July 1, 2013 (Revised 6/16/2021 3/7/2022). I have had the chance to review this Notice.


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FOR OFFICE USE ONLY:


DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.


DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

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