een” NYU Langone Health Notice of Privacy Practices NOTICE OF PRIVACY PRACTICES ACKNOWLEDGMENT FORM By signing this form, I acknowledge that I have received a copy of NYU Langone Health's Notice of Privacy Practices. Patient Name: SFEREN (CE PSTe) Signature: Date: aad | Personal Representative’s Name (if applicable): Personal Representative’s Authority (¢.g., parent, guardian, health care proxy): a sl = Effective as of 11/01/2017. EFTA00313918