NYU Langone
Health NYU Langone Health
Notice of Privacy Practices
NOTICE OF PRIVACY PRACTICES ACKNOWLEDGME
NT FORM
By signing this form, I acknowledge that I have receiv
ed a copy of NW Langone Health's
Notice of Privacy Practices.
Patient Name: Ten= kem
Signature: Date:
Personal Representative's Name (if applicable):
Personal Representative's Authority (e.g., parent, guard
ian, health care prosy):
Effective as of 11101+'2017.
EFTA00313918