Peninsula Gastroenterology Medical Group, Gastroenterologists logo for print
Redwood City: 2900 Whipple Ave | Suite 245 |Redwood City, CA 94062 • Phone: 650-365-3700
Mountain View: 2500 Hospital Drive | Building 8, Suite B | Mountain View, CA 94040 • Phone: 650-964-3636

Peninsula Gastroenterology Medical Group, Gastroenterologists

650-365-3700Redwood City
650-964-3636Mountain View

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.

I authorize Peninsula Gastroenterology Medical Group to discuss my medical
treatment with the following (i.e. spouse, friend, children. There is no need to
list referring physicians):

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

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 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