I acknowledge that on the date indicated on the signature block to this Acknowledgement, I received a copy of Aviator Medical Group PA’s Notice of Privacy Practices and that I read and understood it.

I understand that:

• I have certain rights to privacy regarding my protected health information.

• Aviator Medical Group PA can and will use my PHI for purposes of my treatment, payment, and health care operations.

• The Notice explains in more detail how Aviator Medical Group PA may use and share my protected health information for other purposes.

• I have the rights regarding my protected health information listed in the Notice.

• Aviator Medical Group PA has the right to change the Notice from time to time and I can obtain a current copy of the Notice by contacting us at privacy@aviatorcare.com or (650) 761-9189.