Patient : Hipaa

HIPAA

Policy Date	Acknowledgment	Relationship	Date Received	Paper Sig
			04/03/2018
			05/23/2018

Signature

Reason

Special Restrictions

Non-Routine Disclosures

Created By/On: Devel# 11/26/2015 | 5:23:47 am

Maintained By/On: Rodriguez Maria 02/12/2018 | 5:06:479 am

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Date of Birth

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MRN

Phone

Address

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ZIP

Name	Date of Birth	Address	City	State	ZIP	Phone	Status
Smith James	10/07/1978	88 Center Rd	Bedford	OH	44146	715-361-4850	Active
Rodriguez Maria	10/07/1976	2349 Spinnaker Lane	Joliet	LA	60432	724-376-4350	Active
Smith James	10/07/1978	1566 Elm Drive	Cambridge	NY	12816	532-247-7219	Active