OIMA Patient Packet **PLEASE CHECK IN 15 MINUTES PRIOR TO YOUR APPOINTMENT WITH FORMS COMPLETED**Patient InformationName* First Last Date of Visit* MM slash DD slash YYYY This field is hidden when viewing the formPrimary Provider at Ocotillo Internal Medicine Drew Hall Lily Delatte Nicholas Vlahos, MD Physician(s) You SeeMedicationsPlease list all prescribed or over the counter medications.ListName of MedicationDose ( mg, ml )# of tablets or capsules each dose# of times per day Medication AllergiesHave you had an allergic or adverse reaction to any medication? Yes No List Medication AllergiesMedicationType of Reaction Medical HistoryCheck all that apply.Your Medical History: Hearing loss Cataracts Asthma Hayfever COPD Valley Fever Lung Nodule High Blood Pressure (Hypertension) Heart Attack (myocardial infarction) Congestive Heart Failure Atrial Fibrilation Elevated Cholesterol (hypercholesterolemia) Acid Reflux (GERD) Crohn's Disease Ulcerative Colitis IBS ( irritable bowel syndrome ) Hep. A Hep. B Hep. C Ulcer of stomach or esophagus Chronic Constipation Osteoarthritis Rheumatoid Arthritis Fibromyalgia Lupus Osteoporosis Osteopenia Other Please check all that are applicable.Other:Your Medical History 2: Diabetes Melitus Hypothyroidism (low thyroid) Hyperthyroidism (high thyroid) Menopause (women only) Polycystic ovarian disorder (women only) Kidney disease Kidney stones (nephrolithiasis) Enlarged Prostate (men only) Frequent urinary tract infections Stroke or TIA Migraine headaches Seizures Dementia Parkinson's Disease Skin Cancer Eczema Anemia Leukemia Lymphoma Blood clot Depression Anxiety Eating Disorder Attention Deficit Disorder Bipolar Disease Cancer? Please list type below Please check all that are applicable.Please list types of cancer:Surgical HistoryCheck all that apply.Surgical History Appendectomy Removal of gallbladder (cholecystectomy) Colon surgery Breast surgery Prostrate surgery Tubal ligation Vasectomy Hysterectomy Removal of ovaries (oophorectomy) Join replacement - specify Cardiac Bypass Pacemaker Valve replacement Cardiac catch with stent Other Please check all that are applicable.Joint Replacement details:If Joint replacement or other, please specify below.Other:Family HistoryIs Your Mother Living? Yes No Mother's Deceased/AgeMother Medical Problems Diabetes Heart Disease Breast cancer Colon cancer Is Your Father Living? Yes No Father's Deceased/AgeFather Medical Problems Diabetes Heart Disease Breast cancer Colon cancer Do You Have Sisters? Yes No Sister's Deceased/AgeSisters Medical Problems Diabetes Heart Disease Breast cancer Colon cancer Do You Have Brothers? Yes No Brother's Deceased/AgeBrothers Medical Problems Diabetes Heart Disease Breast cancer Colon cancer Social HistoryWho do you live with?* Self Spouse Family Do you currently smoke?* No Yes How much do you smoke?How many years have you been smoking?Have you ever smoked?* No Yes How many years did you smoke?What year did you quit?Occupation Retired For example, Accountant. If retired, please check box and fill in previous profession.Previous profession:Immunization DatesPlease list the month/year for each immunization.InfluenzaShingles (Shingrix)Shingles (Zostavax)Hepatitis BHepatitis APneumovasPrevnar 13GardisilTetanusTDAPScreening Male and FemaleScreening Male and Female Stool Cards Colonoscopy Bone Density Male & Female Date - Stool Cards MM slash DD slash YYYY Male & Female Date - Colonoscopy MM slash DD slash YYYY Male & Female Date - Bone Density MM slash DD slash YYYY Was the Male and Female Screening Normal? Normal Abnormal Screening MaleScreening Male PSA Testicular Exam Male Date - Testicular Exam MM slash DD slash YYYY Male Date - PSA MM slash DD slash YYYY Was the Male Screening Normal? Normal Abnormal Other:Screening FemaleScreening Female Pap Smear Mammogram Female Date - Pap Smear MM slash DD slash YYYY Female Date - Mammogram MM slash DD slash YYYY Was the Female Screening Normal? Normal Abnormal Review of SymptomsGeneral Weight Loss Weight Gain Fever Chills Fatigue Insomnia HEENT Visual changes Nose congestion Photophobia Nose drainage Eye itching Nose bleeding Eye Redness Sinus congestion Loss of hearing Sore throat Ear infection Hoarse Voice Heart/Vascular Chest Pain Rapid heart rate Irregular heart rhythm Leg swelling Pain in the legs when walking Respiratory Shortness of breath Coughing Wheezing Snoring Breast Breast Lumps Nipple Discharge Gastrointestinal Stomach pain Nausea/vomiting Heartburn Trouble swallowing Diarrhea Constipation Blood in stool Stool incontinence Hemmorrhoids Blood Disorder Bleeding disorder Easy bruising Anemia Lymphatics Enlarged lymph nodes Lymphodema Musculoskeletal Joint pain Joint swelling Muscle pain Back pain Neck pain Fractures Skin Rash Hives Dry Skin Eczema Skin Cancer Nervous System Dizzyness Spinning Numbnes/tingling Gait Disturbance Balance Difficulties Seizures Headaches Psyciatric Depression Anxiety Phobias Eating Disorder Substance Abuse Genitorounary Burning with Urination Frequent Urination Nighttime Urination Urinary Incontinence Blood in the Urine Sexual Difficulties Men Difficulties with Urination Weak Stream Scrotum/Testicular Lump STD's Pre Menopause Irregular Menses Painful Menses Vaginal Discharge STD's Post Menopause Vaginal Dryness Hot flashes/night sweats Vaginal Bleeding STDs Breast Breast lumps Nipple discharge Patient InformationName* First Last Date of Birth* MM slash DD slash YYYY Social Security NumberAddress* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Patient Email* Home PhoneCell Phone*Work PhoneWhat's the best number to reach you? Home Phone Cell Phone Work Phone Gender Male Female Marital StatusSingleMarriedDivorcedWidowedSeparatedPartnerRace American Indian Asian Black or African American Hispanic White Pacific Islander Do Not Wish To Respond Other Other:Ethnicity Not Hispanic Hispanic, Latino Do Not Wish To Respond Other Language Preference English Do Not Wish To Respond Other Other:Employment Status Working Student Retired Disabled Emergency ContactName First Last Relationship to PatientAddress Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home PhoneCell PhonePrimary InsuranceIf you do not have insurance, please type in "NONE" to the fields marked required.Name of Insurance Company*Claim Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Policy / ID Number*Group NumberPolicy Holder Name* First Last Relationship to Patient*Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code EmployerPolicy Holder's Social Security NumberPolicy Holder's Date of Birth* MM slash DD slash YYYY Secondary InsuranceName of Insurance CompanyClaim Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Policy / ID NumberGroup NumberPolicy Holder Name First Last Relationship to PatientAddress Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code EmployerPolicy Holder's Social Security NumberPolicy Holder's Date of Birth MM slash DD slash YYYY Person Responsible for Bills (if different from patient)Name First Last Relationship to PatientAddress Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home PhoneHow long have you smoked?Cell PhoneDoes Patient Have Living Will or Medical Power of Attorney? Yes No If yes, please provide a copy.FileMax. file size: 1 GB. I acknowledge that all of the information given is true and correct and that it has been furnished to this office with full knowledge that, regardless of responsible party listed above, the person signing this document is ultimately liable for all said services rendered and that he/she is contractually bound to pay for said services. Further, by signing below, I give Ocotillo Internal Medicine Associates permission to bill my insurance(s) on my behalf.Patient/Guardian Signature*Date* MM slash DD slash YYYY Email **PLEASE CHECK IN 15 MINUTES PRIOR TO YOUR APPOINTMENT WITH FORMS COMPLETED**What medications are you allergic to?Ocotillo Internal Medicine Associates Financial AgreementInsurance: Ocotillo Internal Medicine Associates (OIMA) is a primary care practice. Your insurance may require that you select a primary care physician. Failure to do so, prior to the office visit, will result in insurance denying full or partial payment of your claims. A copy of your insurance card is required. We are required by our insurance contracts to collect all co-pays at the time of service. This includes annual visits. Any co-pays not received on the day of the visit will be subject to a $10 processing fee. It is your responsibility for knowing the benefits of the specific insurance plan(s) you have purchased. OIMA is not responsible for interpreting these benefits, or knowing how your insurance will process your claims. If your insurance requires a referral it is your responsibility to obtain the referral prior to your appointment with specialist, some insurances take a week to process referrals. Claims Submission: OIMA will file a claim with your insurance company on your behalf. If OIMA is not contracted with your insurance company, you hereby authorize assignment of payment directly to our office for services provided. Self-Pay Patients: Patients without insurance coverage, or coverage that cannot be verified prior to an appointment, shall be responsible for paying the balance in full at the time services are provided. A $65 deposit prior to the appointment is required (cash or credit card). Balances: Unless other arrangements have been made in advance, the balance on accounts are due and payable at either the next appointment or upon the receipt of statement whichever is first. It is the patient’s responsibility to update demographic information at each appointment. If an account becomes past due, OIMA will take the necessary steps to collect this debt. After having mailed three statements, a $20 fee will be added to your account balance. If your account is sent to our outside collections agency, OIMA will assess a $40 collection’s fee. There is a $50 NSF fee for any returned checks. An account that is sent to collections may be discharged from our practice. Patient's Initials*Insurance: Ocotillo Internal Medicine Associates (OIMA) is a primary care practice. Your insurance may require that you select a primary care physician. Failure to do so, prior to the office visit, will result in insurance denying full or partial payment of your claims. A copy of your insurance card is required. We are required by our insurance contracts to collect all co-pays at the time of service. This includes annual visits. Any co-pays not received on the day of the visit will be subject to a $10 processing fee. It is your responsibility for knowing the benefits of the specific insurance plan(s) you have purchased. OIMA is not responsible for interpreting these benefits, or knowing how your insurance will process your claims. If your insurance requires a referral it is your responsibility to obtain the referral prior to your appointment with specialist, some insurances take a week to process referrals. Claims Submission: OIMA will file a claim with your insurance company on your behalf. If OIMA is not contracted with your insurance company, you hereby authorize assignment of payment directly to our office for services provided. Self-Pay Patients: Patients without insurance coverage, or coverage that cannot be verified prior to an appointment, shall be responsible for paying the balance in full at the time services are provided. A $65 deposit prior to the appointment is required (cash or credit card). Balances: Unless other arrangements have been made in advance, the balance on accounts are due and payable at either the next appointment or upon the receipt of statement whichever is first. It is the patient’s responsibility to update demographic information at each appointment. If an account becomes past due, OIMA will take the necessary steps to collect this debt. After having mailed three statements, a $20 fee will be added to your account balance. If your account is sent to our outside collections agency, OIMA will assess a $40 collection’s fee. There is a $50 NSF fee for any returned checks. An account that is sent to collections may be discharged from our practice. Appointments: Patients arriving more than 10 minutes after their appointment time will be asked to reschedule. We require 24 hour advanced notice of cancellation. A $45.00 fee will be applied to your account for short-notice cancellations or missed appointments. A second offense will result in a $90 fee. Patients who miss several appointments without calling may be discharged from our practice. Annual Exam: Ocotillo Internal Medicine provides comprehensive medical care. As such, an annual appointment is required yearly of every patient. A new patient appointment (initial visit) is considered an annual appointment. Annual exams at OIMA consist of the preventive portion as well as the assessment or management of specific symptoms or problems, acute and/or chronic. Insurance companies require all services to be itemized and coded appropriately. These codes are standardized and follow commercial insurance and Medicare guidelines. In order to provide you with the optimal medical care and for your convenience we provide these services in one visit. Please understand that because our annual appointments cover both types of services, some fees may be subject to your plan’s co-pay, deductible or coinsurance and it will be your obligation to pay those fees for which OIMA is contractually obligated to collect. If the preventative code is not covered, per your insurance, our office will charge a $65 fee. Chronic Care Management Services: As part of an ongoing effort to enhance care coordination we are pleased to offer chronic care management services which will help better coordinate your care. Care coordination consists of non-face-to-face care services which Ocotillo will furnish to assist in your care among your different care provider and help you better manage your care. There will no out of pocket cost for this service. Patient's Initials*By signing this agreement, you consent to have Ocotillo Internal Medicine Associates bill your insurance monthly for Chronic Care Management services provided to you by providers at Ocotillo Internal Medicine Associates. Please direct questions to our billing office. You may revoke this consent anytime by written request. There will be no out- of-pocket charges for the patient. BY SIGNING THIS FORM, YOU ACKNOWLEDGE THAT YOU HAVE READ AND UNDERSTAND THIS FINANCIAL AGREEMENT. No changes to this policy by the patient will be acknowledged. Questions may be directed to the billing office. Patient Name* First Last Date* MM slash DD slash YYYY HIPAA Consent FormThe Health and Portability and Accountability Act (HIPAA) provides safegaurds to protect your privacy.List*Patient NameDate of BirthPatient information will be kept confidential except as is necessary to provide services or to ensure that all administrative matters related to your care are handled appropriately. This specifically includes the sharing of information with other healthcare providers, laboratories, health insurance payers as is necessary and appropriate for your care. Patient hereby waives his/her confidentiality rights should collection action become necessary. You have the right to request restrictions in the use of your protected health information and to request change in certain policies used within the office. However, we are not obligated to alter internal policies to conform to your request.My protected health information can be released to the following people:NameRelationshipPhone HIV/AIDS/STD: This form authorizes release of medical information including HIV-related. Confidential HIV-related information is any information indicating that a person has had an HIV-related test, or has HIV infection, HIV-related illness or AIDS, or any information that could indicate a person has been potential exposed to HIV. My Consent* I Consent I Do Not Consent I consent to the release of any positive or negative test result for AIDS/ HIV or STD infection, antibodies to AIDS or infection with any other causative agent of AIDS with the rest of my medical records.Consent*Initials - HIV ConsentDateWith this consent, I give Ocotillo Internal Medicine permission to call my home or other alternative location provided in patient information form and leave a detailed message on voice mail or in person to someone listed above in reference to any items that assist the practice in carrying out treatment, payment, and health care operations, such as appointment reminders, insurance items and any calls pertaining to my clinical care such as lab and test results.This field is hidden when viewing the formPatient Signature [or parent, guardian or legal representation]*Digital Patient Signature [or parent, guardian or legal representation]*Date MM slash DD slash YYYY Release of Medical InformationName First Last Date of Birth MM slash DD slash YYYY I, (enter name), hereby authorize use or disclosure of protected health information about me.Ocotillo Internal Medicine 245 S. Dobson Rd. Chandler, AZ 85224 Phone: 480-895-5870 Fax: 480-895-0573Dr./FacilityAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country PhoneFaxI understand that the information used or disclosed may be subject to re-disclosure by the person receiving it and would the no longer be protected by federal privacy regulations. I may revoke this uathorization by notification in writing of my desire to revoke it. However, I understand that any action taken in reliance on this authorization cannot be reversed, and my recovation will not affect those action. I understand that the provider to whom this authorization is furnished may not condition its treatment or me on whether or not I sign the authorization. This authorization expires two (2) years from the date of execution.Today's Date* MM slash DD slash YYYY Patient's Digital Signature*Acknowledgment of Receipt of Privacy PracticesYou may refuse to sign this acknowledgmentPatient's Digital Signature*This field is hidden when viewing the formSignature*I, have received a copy of this Office's Notice of Privacy Practices.Date MM slash DD slash YYYY Δ
