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Page 1: · acknowledgement form notice of privacy practices the notice describes how medical/protected health information about you may be used and disclosed

Page 2: · acknowledgement form notice of privacy practices the notice describes how medical/protected health information about you may be used and disclosed

Page 3: · acknowledgement form notice of privacy practices the notice describes how medical/protected health information about you may be used and disclosed

Page 4: · acknowledgement form notice of privacy practices the notice describes how medical/protected health information about you may be used and disclosed

Page 5: · acknowledgement form notice of privacy practices the notice describes how medical/protected health information about you may be used and disclosed

Page 6: · acknowledgement form notice of privacy practices the notice describes how medical/protected health information about you may be used and disclosed

Page 7: · acknowledgement form notice of privacy practices the notice describes how medical/protected health information about you may be used and disclosed

Page 8: · acknowledgement form notice of privacy practices the notice describes how medical/protected health information about you may be used and disclosed

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