Patient Privacy Practices
Acknowledgment of Receipt of Notice of Privacy Practices
Peninsula Gastroenterology Medical Group
I hereby acknowledge that I received or reviewed a copy of this medical practice's Notice of Privacy Practices. I further acknowledge that a copy of the current notice will be posted in the patient waiting area, and that I will be offered a copy of any amended Notice of Privacy Practices at each appointment.
Please list below any persons who may be able to access your medical information without first obtaining written consent. Do not list your primary care physician.