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Patient Name (please print) hereby acknowledge receipt of the AFM HIPAA Policy given to me.


It is the policy of Annapolis Family Medicine not to release confidential medical information regarding your treatment to family members or friends, except for (i) parent/legal guardian, (ii) other persons authorized by the patient, (ili) as we may reasonably infer from the circumstances (for example, if you bring a family member or friend into the exam room, we will assume, unless you object, that the person is entitled to receive information regarding your treatment), (iv) in emergency situations, or (v) as otherwise permitted by the Health Insurance Portability and Accountability Act of 1996 (HIPAA). If you anticipate that you will need or want your medical information to be provided to family members, friends, or caregivers, please indicate that below, so that we may best serve you. By signing below, you authorize the following persons to receive information, as requested, regarding your care and treatment. Updates to this form must be made in person.

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Our Office

Annapolis Family Medicine
104 Ridgely Ave, Ste 302
Annapolis, MD 21401

T: 410-280-9500
F: 443-214-5168

Email: afm@annapolisfamilymedicine.org

All office visits are by appointment only:

Business Hours
Monday: 8AM – 5PM
Tuesday: 8AM – 12PM, 1PM – 5PM
Wednesday: 8AM – 5PM
Thursday: 8AM – 5PM
Friday: 8AM – 4PM

**NOTE:  M,W,TH,F – Office phones turned off 12:30PM – 1PM.

Lab Hours
Monday- Friday 8AM-12PM & 1PM-4PM