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.
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.).
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.