Carlos A Lozano MD PA

Available Forms

ACKNOWLEDGEMENT OF REVIEW OF NOTICE OF PRIVACY PRACTICES Additional Insurance Information Form Appointment Request Authorization to Release Medical Information New Patient Information Form Notice of Privacy Practices Prescription Refill Request Request of Medical Records

ACKNOWLEDGEMENT OF REVIEW OF NOTICE OF PRIVACY PRACTICES

Carlos A. Lozano, MD PA

I have reviewed and understand Carlos A. Lozano M.D., Notice of Privacy Practices, which explains how my medical information will be used and disclosed and how I can get access to my medical information.

I know that I may have a copy of the Notice. I also know that from time to time, the Notice of Privacy may be revised. If I want the revised Notice of Privacy Practices, I know I must ask for it.

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Description of Personal Representative's Authority to Act for Patient

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