Patient Information Template Page 6

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Gwinnett Ob/Gyn Associates, P.C.
1700 Tree Lane Road, Ste. 290
Snellville, Georgia 30078
(770) 972-0330
Receipt of Notice of Privacy Practices
Written Acknowledgement Form
I, ____________________________________________, have received and/or reviewed a copy
of Gwinnett Ob/Gyn Associates, P.C.’s Notice of Privacy Practices.
Signature of Patient __________________________________Date_______________________
FILE ON TOP OF ALL CORRESPONDENCE
IN LAST SECTION OF PATIENT CHART

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