Georgia Kidney Associates

Edward D. Himot, MD., Indira Chervu, M.D., F.A.C.P., Robert D. Jansen, M.D., Akin O. Ogundipe, M.D., F.A.C.P.,
Vijay Nath, M.D., Sandeep Jaglan, M.D., Amish Patel, M.D., Kimone James, M.D., Samuel A. Johnson, M.D.

Patient Confidentiality Form

To ensure that there is no violation of your privacy, please provide us with the following information:

In the event that I, (First Name)    (Last Name), cannot be reached, Georgia Kidney Associates, Inc. may leave any test result, lab result, appointment information or other confidential medical information with the following.

Please select all that apply:

Spouse Name: Number:
Children Name: Number:
Name: Number:
Name: Number:
Home Voice Mail Number:
Work Voice Mail Number:
Cell Voice Mail Number:
Other Name: Number:
Name: Number:

If there is anyone you DO NOT wish us to discuss this information with, please specify below.

Patient Signature: Date: