Sitel Mike Training

Step 1 of 3

  • HIPAA PRIVACY ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

  • (Patient's or Patient's legal representative Full legal name here)
  • , have been presented with the Notice of Privacy Policy of Dr. Ariel Medina, and have been offered a copy of such policy to keep for my records.
  • Date Format: MM slash DD slash YYYY
  • MEDICAL DIGITAL VIDEO AND PHOTO CONSENT

  • (Patient's or Patient's legal representative Full legal name here)
  • understand that photographs, videotapes, digital, or other images may be recorded to document my care, and I consent to this. I understand that Dr. Ariel Medina will retain the ownership rights to these photographs, videotapes, digital, or other images, but that I will be allowed access to view them or obtain copies. I understand that these images will be stored in a secure manner that will protect my privacy and that they will be kept for the time period required by law. Images that identify me will be released and/or used outside the institution only upon written authorization from me or my legal representative.
  • Date Format: MM slash DD slash YYYY