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Welcome to Pulmonary Medicine of Dayton, Inc. We look forward to serving you. Kindly fill out - page 6 / 8

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Pulmonary Medicine of Dayton Privacy Practices

The staff of Pulmonary Medicine of Dayton, Inc. will not directly use or allow the use of Pulmonary Medicine of Dayton data for any purpose other than that directly associated with any official assigned duties. We understand that all patient’s information including financial data will be held strictly confidential. Official HIPAA manual is available for your review.

You have my permission to discuss my medical record information and account with the following individuals:

Name

Relationship

Phone

___________________________ ___________________ _____________

___________________________ ___________________ _____________

___________________________ ___________________ _____________

I have received Pulmonary Medicine of Dayton, Inc.’s Notice of Privacy Practices.

Name (Please Print):_____________________________________

Signature:

_____________________________________________

Witness:

_______________________________________________

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