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.
Authorization to Use and Disclose Protected Health Information
I authorize release of my protected health information to: