Center for Colposcopy
Mark Spitzer, MD P.C. FACOG
Gynecology, Colposcopy,
Treatment of Vulvovaginal Diseases
Notice of Privacy Practices Acknowledgment and consent
By signing below, I acknowledge that I have been provided a copy of this Notice of Privacy Practices and have therefore been advised of how health information about me may be used and disclosed by Mark Spitzer, MD P.C. and how I may obtain access to and control this information. I also acknowledge and understand that I may request copies of separate notices explaining special privacy protections that may apply to HIV-related information, alcohol and substance abuse treatment information, mental health information, and genetic information. Finally, by signing below, I consent to the use and disclosure of my health information to treat me and arrange for mine medical care, to seek and receive payment for services given to me, and for the business operations of the organization, its staff, and its facilities listed in the Notice of Privacy Practices.
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Signature of patient or Relationship to patient Date
authorized representative
Notice of Privacy Practices Affirmation of prior receipt
By signing below, I acknowledge that I have already received a copy of the Notice of Privacy Practices and have given my consent for the use of my health information for the purposes noted above. I do not wish to receive another copy of the Notice of Privacy Practices at this time.
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Signature of patient or Relationship to patient Date
authorized representative
release of information to government agencies, insurance carriers or other entities representing the provider
The provider may release to government agencies, insurance carriers or their designated agents or the legal or financial departments representing me or the provider, all information needed to substantiate payment for my medical care and permit representatives thereof to examine and make copies of all records relating to such care and treatment.
Date: ______Signed: ______
1991 Marcus Avenue, Suite M215Lake Success, NY 11042
Phone: 516-355-7802 Fax: 516-467-1387