GCD - HIPAA

GARDEN CITY DERMATOLOGY
901 Stewart Avenue, Suite 201, Garden City, New York 11530
Phone: 516-227-3377 Fax: 516-227-3378

RECEIPT OF NOTICE OF PRIVACY PRACTICES WRITTEN ACKNOWLEDGEMENT FORM
Patient Name*
I, {patientName}, have had an opportunity to read and receive a copy of Garden City Dermatology’s Notice of Privacy Practices.

I authorize Garden City Dermatology to leave information regarding my medical treatment on my voicemail or answering machine unless otherwise informed. I authorize Garden City Dermatology to discuss my Protected Health Information (PHI) (i.e. laboratory results, biopsy results) with the following family members:
Name
Relationship
Signature*

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Date*

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GARDEN CITY DERMATOLOGY