EFTA00314096

Receipt of Notice of Privacy Practices Written Acknowledgement Form MITCHELL A. KLINE ALA, P.C. DERMATOLOGY/DERMATOLOGIC AND COSMETIC SURGERY I am a patient of MITCHELL A. KLINE M.D., P.C. and have reviewed MITCHELL A. KLINE MD., P.C.'s Notice of Privacy Practices. A copy of the notice is available upon request. Name [please print]: ILSE F R C s4 E ESTE I Signature: Date: pi . l '01 -1 OR I am a parent or legal guardian of [patient name]. I hereby acknowledge receipt of MITCHELL A. KLINE M.D.. P.0 Notice of Privacy Practices with respect to the patient. Name [please print]: Relationship to Patient: O Parent O Legal Guardian Signature: Date: September 23. 2013 EFTA00314096