NOTICE OF PRIVATE POLICY
As required by the privacy regulations created as a result of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). This notice describes how health information about you (as a patient of this practice) may be used and disclosed an how you can get access to your individually identifiable health information.
Patient Name
First Name
Last Name
Parent /Legal Guardian Name
First Name
Last Name
Parent /Legal Guardian Signature
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Please review this notice carefully and check the box that you agree to these terms.
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