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Download Patient - Snake River Pediatrics
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Snake River PEDIATRICS Infants, Children, & Adolescents 1050 SW 3rd Ave, Suite 3200 • Ontario, OR 97914 • (541) 881-2380 • Fax (541)881-2389 Stephen Ames, MD, FAAP • Matthew Berria, PhD, PA-C • Sage Benintendi Stringer, MPAS, PA-C • Michelle DeVoe, DO, FAAP Mary James, MPAS, PA-C • Chelsie Lewis, FNP-C • Kailey Meskill, MPAS, PA-C Acknowledgement of Notice of Privacy Practices I have been presented with a copy of the Notice of Privacy Practices for the office of Snake River Pediatrics, P.C., detailing how my information may be used and disclosed as permitted under federal and state law. Signed: _______________________________________ Date: _____________ If not signed by patient, please indicate relationship to patient (e.g., mother) and patient’s name. Patient: ______________________________________ Relationship: _________________________________
