I certify that the information above is true and complete to the best of my knowledge. I acknowledge that I have received Riverstone Family Medicine's Notice of Privacy Practices describing how my protected health information may be used and disclosed under HIPAA, and I consent to evaluation and treatment by the practice's clinicians.

I understand I am financially responsible for any balance not covered by my insurance, and I authorize the practice to release information to my insurer as needed to process claims.