Acknowledgment of Receipt of Notice of Privacy Practices

Patient Name:

Date of Birth: Please leave this field empty.

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: