Acknowledgement of Receipt of Privacy Notice

I have been presented with a copy of the Notice of Privacy Policies, detailing how my information may be used and disclosed as permitted under federal and state law. I understand the contents of the Notice.

I authorize the release of any medical information necessary to process my insurance claims and for peer review for accreditation purposes.

I understand that I am responsible for any amount not covered by: insurance deductible and co-pays.

First Name

Last Name

Email

I agree with the above terms