Acknowledgment of Receipt of Notice of Privacy Practices

IF YOU WISH ANYONE OTHER THAN YOUR INSURANCE CARRIER OR REFERRING PHYSICIAN TO HAVE ACCESS OR SPEAK TO OUR OFFICE REGARDING YOU AND YOUR PERSONAL HEALTH INFORMATION, YOU MUST LIST THEIR NAMES AND RELATIONSHIP TO YOU IN THE AREA DESIGNATED BELOW ALONG WITH YOUR SIGNATURE. THIS SIGNATURE WILL REMAIN VALID UNLESS THIS OFFICE IS OTHERWISE INSTRUCTED BY YOU.

I AUTHORIZE THE RELEASE OF MY PATIENT HEALTH INFORMATION (PHI) TO THE FOLLOWING PERSONS:

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Name Relationship

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Name Relationship

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Name Relationship

Kyle D. Parish, MD, PSC reserves the right to modify the privacy practices outlined in the notice.

Signature

I have received a copy of the Notice of Privacy Practices for Kyle D. Parish, MD, PSC

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Name of Patient (Print)

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Signature of Patient Date

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Signature of Patient Representative (Required if the patient is a minor or an adult who is unable to sign this form)

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Relationship of Patient Representative to Patient