PRIMARY
Secondary
Acknowledgement of Receipt of Privacy NoticeBy signing below, I hereby acknowledge that I am aware of the Privacy Practices that Affiliated Troy Dermatologists has in place. I can request a copy of this privacy agreement for my records at any time.
I,{patientsName} , authorize Affiliated Troy Dermatologists to give personal information to the following people in the event that they call and have questions regarding medical condition(s):
I, {parentguardianName}, {patientsName}'s parent/guardian, authorize Affiliated Troy Dermatologists to give personal information to the following people in the event that they call and have questions regarding medical condition(s):
I have read and understand the above and allow Affiliated Troy Dermatologists to give personal information to the above listed persons.
As the patient or parent/guardian of the patient, I agree to the following: