WRITTEN ACKNOWLEDGEMENT FORM. I, ____________________, have received a copy of DANIEL K. HELLERSTEIN MD PA's Notice of Privacy Practices.
Signature of Patient Date 
DANIEL K. HELLERSTEIN, M.D., P.A.
1411 North Flagler Drive
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WRITTEN ACKNOWLEDGEMENT FORM. I, ____________________, have received a copy of DANIEL K. HELLERSTEIN MD PA's Notice of Privacy Practices.
Signature of Patient Date
DANIEL K. HELLERSTEIN, M.D., P.A.
1411 North Flagler Drive
|