Privacy Practices Form

I acknowledge that I have had the opportunity to review a copy of Atlanta Women's Health Group, P.C. (“AWHG”) Notice of Privacy Practices (“Notice”). I understand that I am responsible to read this Notice and notify AWHG, in writing, of any request for restrictions in the use or disclosure of my protected health information (“PHI”). I understand AWHG has the right to revise this Notice at any time and will post a copy of the current Notice in the office in a visible location at all times and on their website at www.awhg.org. AWHG will provide me with a copy of its most recent Notice upon request.

Patient First Name

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Patient Last Name

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By submitting your signature, the parties agree that this agreement may be electronically signed. The parties agree that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.