Hipaa Patient Consent Form - Unique Dermatology Wellness Page 2
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1
2Complete this section if this form is not signed and dated by the patient or patient’s personal representative.
I have made a good faith effort to obtain a written acknowledgement of receipt of Unique Dermatology & Wellness
Centers Notice of Privacy Practices but was unable to for the following reason:
Patient refused to sign
Patient unable to sign
O
Other________________________________
Employee Name:_______________________________________________
Date:___________________________________
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