Signature If completed by a patient's personal representative, please print and sign your name in the space below Personal Representative (Print) Personal Representative's Signature Relationship For ColumbiaDoctors use only Complete this section if this form is not signed and dated by the patient or patient's person

form, I acknowledge that I have received a copy of NW Langone Health's Notice of Privacy Practices. Patient Name: Ten= kem Signature: Date: Personal Representative's Name (if applicable): Personal Representative's Authority (e.g., parent, guardian, health care prosy): Effective as of 11101 +'2017. EFTA00313918

ning this form, I acknowledge that I have received a copy of NYU Langone Health's Notice of Privacy Practices. Patient Name: Signature: Date: Personal Representative's Name (if applicable): Personal Representative's Authority (e.g., parent, guardian, health care pt-ox Effective as of 11/01/2017. EFTA00308061 BE