Patient Forms Online Resources Frequently Asked Questions Glossary of Terms Be an egg donor	Patient Resources - Patient Forms In order to make your visits with us as convenient as possible, we have made several of our most commonly used forms available for downloading and printing. We may refer you to this section of the web site in order for you to easily acquire paperwork that you may need either before an appointment or during your treatment cycle. We will continue to update this section as necessary. If you have a suggestion of a document that you would like to see added to this section of our web site, please let us know. Contact Message Consent Feedback Form Medical History Form Medical Records Release Form Patient Registration Form HIPAA Notice of Privacy Practices

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Office Locations: Coming Soon:

(800) 865-5431 • E-mail: inquiries@rmact.com 10 Glover Avenue • Norwalk, Connecticut (CT) 06850 67 Sand Pit Road • Suite 300 • Danbury, Connecticut (CT) 06810 70 Maple Avenue • Rye, New York (NY) 10580 40 East Putnam Avenue, 1st Floor • Greenwich, Connecticut (CT)

Notice of Privacy Practices

This Notice of Privacy Practices (the “Notice”) is meant to inform you of the uses and disclosures of protected health information (“PHI”) that we may make. It also describes your rights to access and control of you protected health information and certain obligations we have regarding the use and disclosure of your PHI.

Your PHI is information about you created and received by us, including demographic information, that may reasonably identify you and that relates to your past, present or future physical or mental health or condition, or payment for the provision of your health care.

We are required by law to maintain the privacy of your PHI. We also are required by law to provide you with this Notice of our legal duties and privacy practices with respect to your PHI and to abide by the terms of the Notice that is currently in effect. However, we may change our Notice at any time. The new revised Notice will apply to all of your PHI maintained by us. You will not automatically receive a revised Notice. It will be posted on this website, or you may contact your Patient Coordinator, or ask at your next appointment.