HIPAA Form "*" indicates required fields I have been provided with a Notice of Privacy Practices, in compliance with HIPAA regulators. I have read and understand my rights under HIPAA as provided to me by Renu Med Spa. I authorize Renu Med Spa to contact me for the following reasons: • Permission to call me at home, office, or mobile to confirm or reschedule an appointment or to return my message(s). • Permission to leave appointment reminders or appointment cancellation notifcations on an answering machine, with a family member, secretary, or house hold employee. • Permission to mail reminder postcards regarding appointments. These services are provided as courtesy by our practice. I understand that by giving my permission for the above services, I have in no way authorized the release of any confidential medical information. Patient Name* Email* Signature*Date* MM slash DD slash YYYY PhoneThis field is for validation purposes and should be left unchanged. Δ