Acknowledgement Of Receipt Of Notice Of Privacy Practices

Purpose of Consent: By signing this form, you will consent to our use and disclosure of your protected health information to carry out treatment, payment activities, and healthcare operations.

have received a copy of this office’s Notice of
Privacy Practices. I have had full opportunity to read and consider the contents of this Consent form and your Notice of Privacy Practices. I understand that, by signing this Consent form, I am giving my consent to your use and disclosure of my protected health information to carry out treatment; payment activities and heath care operations.

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.

Signature

Date

If a personal representative on behalf of the patient signs this Consent, complete the following:

Personal Representative’s Name

Relationship to Patient

Your information will be encrypted.