The undersigned does hereby acknowledge that he or she has received a copy of this office’s Notice of Privacy Practices Pursuant To HIPAA and has been advised that a full copy of this office’s HIPAA Compliance Manual is available upon request.

The undersign does hereby consent to the use of his or her health information in a manner consistent with the Notice of Privacy Practices Pursuant to HIPAA, the HIPAA

Compliance Manual, State law and Federal Law.