HIPAA Patient Form

Please download, print out and fill out this form DOWNLOAD FORM

We at Debra Jaliman MD are required by law to maintain the privacy of and provide individuals with the provided notice of our legal duties and privacy practices with respect to protected health information. If you have any objections to the notice, please ask to speak with our HIPAA Compliance Officer in person or by phone at our main phone number.

By signing, you acknowledge receipt of HIPAA statement and fully understand its content.

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Patient or Guardian Signature

_______________________ Date: _______________
Print Name