Protecting the privacy of your medical information is required by law and we respect and carefully abide by that law. You should carefully read these forms - and then acknowledge your acceptance of their condition by signing should you choose to do so. These forms must be completed and returned to the clinic at the time of the patient's first visit. You should list names of person(s) that are permitted to access to your (or the patient's) protected health information. No information will be shared with anyone who is not listed on this form.