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