Receipt of Notice of Privacy Practices Written Acknowledgement Form MITCHELL A. KLINE M.D., P.C. DERMATOLOG Y/DERMATOLOGIC AND COSMETIC SURGERY 1 am a patient of MITCHELL A. KLINE M.D., P.C. and have reviewed MITCHELL A. KLINE M._D., P.C.'s Notice of Privacy Practices. A copy of the notice is available upon request. Name (please print: IGE FREN EPSTesa) Signature: — Date: JAA). LL, BAVA OR I am a parent or legal guardian of [patient name]. I hereby acknowledge receipt of MITCHELL A. KLINE M_D., P.C Notice of Privacy Practices with respect to the patient. Name [please print]: Relationship to Patient: O Parent O Legal Guardian Signature: Date: September 23, 2013 EFTA00314096