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RUB PEDIATRICS MD PA 1190 NW 95th St, Suite 409 Miami, FL 33150 (305)696-9490 (305) 696-6225 FAX

21110 Biscayne Boulevard, Suite 308 Aventura, FL. 33180 (305) 932-1007 (305) 696-6225 FAX

website: http://rubpediatrics.com y email: info@rubpediatrics.com

Health Insurance Portability and Accountability Act of 1996 (HIPAA)

NOTICE OF PRIVACY PRACTICES

I, __________________________________________________, as parent or legal PLEASE PRINT FULL NAME

guardian of: Child #1: ____________________________________________

Date of Birth: ________________

Child #2: ____________________________________________

Date of Birth: ________________

Child #3: ____________________________________________

Date of Birth: ________________

Child #4: ____________________________________________

Date of Birth: ________________

Child #5: ____________________________________________

Date of Birth: ________________

Child #6: ____________________________________________

Date of Birth: ________________

agree that I have received a copy of Rub Pediatrics MD PA’s HIPAA NOTICE OF PRIVACY PRACTICES.

Patient / Parent / Legal Guardian Signature: _________________________________ Date: _______________________

Witness: __________________________________


Health Insurance Portability and Accountability Act of 1996 (HIPAA)