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HIPAA Authorization Form

Jeffrey Farkas MD LLC
DBA Interventional Neuro Associates

Jeffrey Farkas, MD | Karthikeyan M. Arcot, MD |David T. Parrella, MD |Ambooj Tiwari, MD, MPH | Clara D. Boyd, MD | Ketevan Berekashvili, MD | Jeremy Liff, MD| Miguel L. S. Litao, MD | Brent Flusty, DO

 

Jeffrey Farkas, MD, LLC
DBA, Interventional Neuro Associates

HIPAA- Health Insurance Portability and Accountability Act



Dear Patient:

As required by privacy regulation mandated by HIPAA – Health Insurance Portability and Accountability Act, we are providing you with our notice of Privacy Practices. We like to assure you we are fully committed to protecting your privacy. Please acknowledge receipt of Jeffrey Farkas, MD, LLC’s notice of Privacy Practices by signing your name below.

I acknowledge receipt of Jeffrey Farkas, MD, LLC, DBA, Interventional Neuro Associates Notice of Privacy Practices.

 

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Signature of Patient                                                                                      Date

 

 

 

 

 

 

 

211 61st St, Brooklyn, NY 11220 | Tel: (718) 630 1270 | 2200 Northern Blvd, suite 207, East Hills, NY 11576 |Tel: (516) 612-9409 |1 Journal Square Plaza, 2nd Fl, Jersey City, NJ, 07306 | Tel: (201) 387-1957 | Fax: 1 201 351-0656 |

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