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    Patient Name:

    Date of Birth:

    HIPAA -- Notice of Privacy Practices

    • I have been provided with a copy of CVMG Joint Notice of Privacy Practices.
    • I know that the Notice may be changed at any time.
    • I may get a new copy of the Notice on the CVMG website or by writing to the Cardiovascular Medical Group, 414 N. Camden Drive, Suite 1100, Beverly Hills, CA 90210

    Patient Signature:

    Click and drag in the space above to sign.

    Date/Time:

    If not patient, describe the nature of your relationship to Patient: