ACKNOWLEDGMENT NOTICE OF PRIVACY PRACTICES

I hereby acknowledge that a copy of The ROSENBERG COOLEY METCALF CLINIC'S Notice of Privacy Practices was provided to me. I further acknowledge and understand that if I have any questions about The ROSENBERG COOLEY METCALF CLINIC'S privacy practices or my rights with regard to my personal health information, I may contact the appropriate person for further information as set forth in the Notice.

Name of Patient (and Patient's Representative, if one)
Date of Birth
Patient Identification #
Patient Signature
Signature of Patient (or Patient's Representative):
Date:

Authorization to Use and Disclose Protected Health Information

I authorize release of my protected health information to:

Name:
Relationship

Start typing and press Enter to search