Andrew Cassidy, DPM
Acknowledgment of Receipt of Privacy Notice
I have been provided with a Notice of Privacy Practices that provides me a more complete description of the uses and disclosures of certain health information. I understand Andrew Cassidy, DPM, reserves the right to change their Notice of Privacy Practices. I may request a copy of the updated Notice of Privacy Practices by calling my physician’s office or requesting a copy in person at my appointment.
The duration of this authorization is indefinite unless otherwise revoked in writing. I understand that requests for medical information from persons not listed below will require a specific authorization prior to disclosure of any medical information.