ACKNOWLEDGEMENT OF RECEIPT OF NOTICE

I acknowledge that I received the NOTICE OF PRIVACY PRACTICES for

Ear, Nose, Throat & Facial Plastic Associates of Montgomery County, Ltd.

Name of Patient: ___________________________________________________

Date of Receipt:_____________________________

Signature of Patient:________________________________________________

(or patient’s personal representative)

Personal representative information ( if applicable):

Name of personal representative__________________________________________

Relationship to patient ( or other authority) _________________________________

I hereby authorize you to discuss or release any of my information to the following:

Signature of Patient or Personal Representative:______________________________