HIPAA Statment

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Edward Ventresca, MD, FCCP, DABSM

Mohammad A. Khan,MD,FCCP,DABSM

ACKNOWLEDGEMENT OF PRIVACY PRACTICES STATEMENT

I hereby certify that I have been given the opportunity to review and/or receive a copy of the Practice’s policy regarding protected health information in accordance with HIPAA regulations.

I give Niagara Pulmonary & Sleep Medicine, PC permission to discuss my medical Condition with the following people:

Please enter name/relationship each on a separate line. Example: John Smith/Father. Please enter "None" if you have no no one to discuss your medical condition with.