Notice of Privacy Policies/HIPAA Name * First Name Last Name Email address * Mobile Phone Number * (###) ### #### Date of Birth * MM DD YYYY Today's Date MM DD YYYY * I have had full opportunity to read and consider the contents of the Notice of Privacy Practices. I understand that I am giving my permission to your use and disclosure of my protected health information in order to carry out treatment, payment activities, and healthcare operations. I also understand that I have the right to revoke permission. I Agree Signature * Please Type Your Full Name Please review to ensure the details are correct before completion. Thank you!