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PHI and Notice of Privacy Forms

Following are PHI (Protected Health Information) and Notice of Privacy Forms.  Please read the Notice of Privacy Policy, and print out and sign the Acknowledgment of Privacy Practices Form and bring it with you to the office.

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Notice of Privacy Policy:  This notice describes how medical information about you may be used and disclosed, and how you can get access to this information.

Acknowledgment of Receipt of Privacy Practices Form: Please sign and bring with you to the office.

Authorization to disclose PHI Form: This form should be filled out by patients who would like to pick up a copy of their medical records or request Saratoga hospital/RMG records be sent to other physicians/facility.

Authorization to Release Health Information HIPAA: This 2-page form should be filled out by patients to request their medical records be sent to us from anther physician/facility.

254 Church Street, Saratoga Springs NY 12866 | 518-866-5080

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