ILM — New Patient Intake

Your information is protected under HIPAA and will only be used for treatment, payment, and healthcare operations.

Step 1 of 22HIPAA PRIVACY ACKNOWLEDGMENT

HIPAA PRIVACY ACKNOWLEDGMENT

I acknowledge I have received and read the Notice of Privacy Practices of this clinic. I understand my Protected Health Information (PHI) will be used for treatment, payment, and healthcare operations. I understand I have the right to access, amend, and request restrictions on my health information.

I acknowledge I have received and read the Notice of Privacy Practices *

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Signature *

Typing your name here is your legal signature. The date and time are recorded with it.

This clinic does not provide emergency services. If this is an emergency, call 911.

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