New Obstetrical Patient Information Form Page 13

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J
A. G
, MD
UDITH
URDIAN
M
S
, MD
ICHELLE
PECTOR
P
E. S
, PA-C
ATRICIA
HEVOCK
M
T
-H
, CNM
ELANIE
HORNTON
UYCKE
You may contact Kathy Heinz, Vice President of Operations 301.340.8339 ext. 201
We are required by law to maintain the privacy of, and provide individuals with, this notice of our legal duties and privacy practices
with respect to PHI. We are also required to abide by the terms of the notice currently in effect. If you have any questions in
reference to this form, please ask to speak with our HIPAA Compliance Officer in person or by phone at our main phone number
301.762.5501.
I have read and understand the privacy practices of Capital Women’s Care, LLC.
_____________________________________________________________________________
____/____/______
Patient/Guardian’s Signature
Date
Healthcare for w om en, by w om en…
9711 Medical Center Drive, Suite 109, Rockville, MD 20850
|
301.762.5501
|
Fax 301.309.8727
13

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