Name *(Required) E-mail *(Required) ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES Finally Health Medical Services, PC reserves the right to modify the privacy practices outlined in the notice. I have received a copy of the Notice of Privacy Practices for Finally Health Medical Services, PC. Name of Patient Date (mm/dd/yyyy) Name of Patient Representative(Require if the patient is a minor or an adult who is unable to sign this form) Relationship of Patient Representative to Patient Enter Code Verification Code
I have received a copy of the Notice of Privacy Practices for Finally Health Medical Services, PC.
