EFTA00310781Set 9
3p1,442w
health care provided to you, including billing, collecti
linter' the name of the Practicel understands that yOur management. determ inations of eligibil ity and COW 3SC and oh,
information ... SAMPLE ACKNOWLEDGMENT
provided with a copy of 'Insert nai
, acknowledge that I have been
Practicel's privacy notice.
Date. , 200
provid
Guide, the privacy regulations require health care
(Note
https://www.justice.gov/epstein/files/DataSet%209/EFTA00310781.pdf