Case File
efta-efta00313918DOJ Data Set 9OtherNYU Langone
Date
Unknown
Source
DOJ Data Set 9
Reference
efta-efta00313918
Pages
1
Persons
0
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NYU Langone
Health
NYU Langone Health
Notice of Privacy Practices
NOTICE OF PRIVACY PRACTICES ACKNOWLEDGMENT FORM
By signing this form, I acknowledge that I have received a copy of NW Langone Health's
Notice of Privacy Practices.
Patient Name: Ten= kem
Signature:
Personal Representative's Name (if applicable):
Personal Representative's Authority (e.g., parent, guardian, health care prosy):
Effective as of 11101 +'2017.
EFTA00313918
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