Patient Privacy Practices

Acknowledgment of Receipt of Notice of Privacy Practices

Peninsula Gastroenterology Medical Group
2900 Whipple Avenue Suite 245, Redwood City, CA 94062
Privacy Officer Telephone Number 650-365-3700

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.

Name of Person	Relationship to Patient
Name of Person	Relationship to Patient
Name of Person	Relationship to Patient
Name of Person	Relationship to Patient

Your Name

Telephone

I authorize Peninsula Gastroenterology Medical Group to discuss the details of my medical treatment with the above named parties.

Should inaccurate or omitted insurance information be supplied causing a reduction or non-payment of benefits, the obligation of payment will be transferred to the responsible party. I hereby authorize the release of any medical information necessary for the processing of insurance. I hereby assign all medical and/or surgical benefits to include major medical benefits to which I am entitled to Peninsula GI. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment, or an electronic copy, is to be considered as valid as an original.

I Agree

I understand that I am providing my consent via e-signature by typing my name and clicking submit.

Signature / E-Signature

Date

If not signed by the patient, please indicate relationship below:
Parent or Guardian of Minor Patient
Guardian or Conservator of an incompetent Patient
Beneficiary or personal representative of deceased patient

Patient Name

IP Address

Atherton Endoscopy Center

Map & Directions

While you are a patient at Atherton Endoscopy Center, our highly competent and professional staff will care for you. Everyone from the receptionist to the physician embraces our philosophy of patient-focused care. Above all, our staff is friendly and concerned for your comfort.