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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)  
Health Insurance Portability and Accountability Act of 1996 (HIPAA)  

Advising you of our offices conformation with the HIPAA laws regarding your privacy. A copy of our Notice of Privacy Practices can be found...