7500 Hugh Daniel Drive
Suite 250
Birmingham, AL 35242
(205) 991-3300 Phone
(205) 991-3327 Fax

NOTICE OF PRIVACY PRACTICES

I, _____________________________, acknowledge that I have received the Notice of Privacy Practices. I have also been given the opportunity to ask questions about this notice and to request additional restrictions on the Practice’s use and disclosure of my personal health information, or to request additional confidential treatment of communications between the Practice and myself or others.

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Signature Date