We invite you to discuss with us any questions regarding our services. The best health services are based on a friendly, mutual understanding between provider and patient.
HIPAA Compliance - Our office is required by law to maintain the HIPAA Notice of Privacy Practices. This notice explains our legal duties and privacy practices with respect to your protected health insurance. Signature below acknowledges that I have read this Notice of our Privacy Practices. A copy will be provided to me upon request.
I authorize the staff to perform any necessary medical services needed during diagnosis and treatment.
I understand the above information and guarantee this form was completed correctly to the best of my knowledge and understand it is my responsibility to inform this office of any changes to the information I have provided.