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
By checking this box and typing my name below, I am electronically signing this form.

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