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    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.

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