Acknowledgment of Receipt of Notice of Privacy Practices

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has received a copy of this office’s Notice of Privacy Practices.

I understand that in order for information to be disclosed to anyone other than myself, I must give permission to Erena & Peterson, PLLC.

I give permission for Erena & Peterson, PLLC to discuss information regarding my care/treatment/account to the following listed persons. ***Note: Please check all that apply and write in names:

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