7655 Five Mile Road Suite 207 Cincinnati, OH 45230
513-232-4110 Fax: 513-232-4949
*Patient First Name:   *Patient Last Name:  
Date of Birth:  
I have received this practice’s Notice of Privacy Practices written in plain language. The Notice provides details regarding the manner in which my protected health information may be used by the practice, as well as information about my individual rights, how I may exercise these rights, and the practice’s legal duties with respect to my information.
I understand that this practice reserves the right to change the terms of its Notice of Privacy Practice’s, and to make changes regarding all protected health information resident at or controlled by, this practice. If changes to the policy occur, this practice will provide me with a revised Notice of Privacy Practices upon request.
Responsible Party Signature:
Relationship to patient (if signed by a personal rep. of patient):