Consent Form - Privacy Practices

Z Medi Clinics and Z Medi Spa

Written acknowledgement of receipt of notice of privacy practices

By signing below, you acknowledge receiving the Z MED Clinics – Notice of Privacy Practices (“Notice”). The Notice explains how Z Med Clinic may use and disclose your protected health information for treatment, payment, and health care operations purposes. “Protected Health Information” means your personal health information found in your medical and billing records.

Z MED Clinics – reserves the right to change the Notice from time to time. A copy of the current Notice or a summary of the current Notice will be posted at patient service locations throughout Z Med Clinic. The effective date of the Notice will appear on the first page of the Notice or summary. In addition, Z Med Clinic will have available for you, at your request, a copy of the current Notice in effect.

YOUR SIGNATURE BELOW ONLY ACKNOWLEDGES THAT YOU HAVE RECEIVED THE NOTICE.

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I (we), the undersigned, authorize and request Z Medi Spa to charge my credit card, indicated above, for balances due for services/cancellations rendered that is my financial responsibility. This authorization will remain in effect until I (we) cancel this authorization. - Signature

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