Independence Women's Clinic

Acknowledgement of Receipt of Notice of Privacy Practices / Communication Authorization

 Method of Disclosure 
Please provide all patient contacts that may be used for communications from Independence Women's Clinic:
 Permission to Disclose Protected Health Information 
I give Independence Women's Clinic permission to disclose my protected health information to the following individuals involved in my health care and/or payment for health care goods and services.
I acknowledge that I have received a copy of Independence Women's Clinic’s
Notice of Privacy Practices with the effective date of July 1, 2015.

Patient/Guarantor/Legal Representative Signature – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button I understand and agree that this is a legal representation of my signature.
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