Receipt of Notice of Privacy Practices Acknowledgement Form

Fort Bend Skin Cancer Center

281.980.6647

Patient Information

First Name

Last Name

Email address

Phone Number

You may be contacted by this office to remind you of appointments, treatment options, test results, or other health services that may be of interest to you.

Contact by Phone

May we contact you and leave a message with our office name and what the call is in reference to?

Yes

If so, please answer questions below

May we contact you at home?

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Home number

May we contact you via mobile phone?

Yes No

Mobile number

May we contact you at work?

Yes No

Work number

Comment (if any)

Is there anyone we can leave a message with?

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First Name

Last Name

Phone Number

Relationship to you

Contact by Text Message

May we send appointment reminders to you by text message?

Yes No

Personal Representative

Would you like to authorize an individual as your personal representative?

Yes No

First Name

Last Name

Phone Number

Relationship to you

HIPAA Notice of Privacy Practices

Fort Bend Skin Cancer Center has provided me with a copy of my rights as a patient under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). (THE LINK TO THIS DOCUMENT CAN BE FOUND IMMEDIATELY ABOVE.)

I have been provided the opportunity to read and understand my rights. If I have questions regarding my rights, I will be given the opportunity to receive answers to my satisfaction.

I agree I disagree

Signature of Patient or Authorized Person

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Keith E. Schulze, M.D.

Dr. Keith Schulze, a fellowship trained member of the American College of Mohs Surgery, opened the Fort Bend Skin Cancer Center in February 2007 after practicing in the Texas Medical Center for six years. His practice is dedicated to the treatment of skin cancer, reconstructive surgery after skin cancer removal, and the surgical treatment of benign skin lesions. Mohs micrographic surgery is a highly specialized treatment for skin cancer that offers the highest potential for cure while minimizing the cosmetic impact; even if previous treatments have failed. With advanced fellowship training as a Mohs surgeon, Dr. Schulze can provide both the thorough diagnosis and effective treatment you need to address your condition.