Notice of Privacy Practices Receipt & Acknowledgement of Notices -

Patient Name*

Enter your full name

Date of Birth*

Enter your date of birth

I hereby acknowledge that I have received and have been given an opportunity to read a copy of privacy practices for Penfield Psychiatry/Finger Lakes Psychiatry. I understand that if I have any questions regarding the Notice or my privacy rights, I can contact Penfield Psychiatry/Finger Lake Psychiatry.

Parent, Guardian or Personal Representative

*If you are signing as a personal representative of an individual, please also describe your legal authority to act for this individual (power of attorney, healthcare surrogate, etc.).

Date*

Electronic Consent*

By checking the "I Accept" box, you are signing this agreement electronically. You agree your electronic signature is the legal equivalent of your manual signature on this agreement. By selecting "I Accept" you consent to be legally bound by this agreement's terms and conditions.

I Accept

Comments

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