Patient Acknowledgement and Consent Form for use and disclosure of Protected Health Information (PHI)
Our Notice of Privacy practices provides information about how we may use and disclose protected health information about you and your rights with respect to your health information. By signing this form, you acknowledge that you have been provided with our Notice of Privacy Practices to review.
By signing this form, you also instruct this practice to release your medical and/or financial information according to the criteria listed below:
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