Ability and Empowerment Services Ability and Empowerment Patient Sign-In · secured in accordance with HIPAA
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Patient

2

Reason for Visit

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Patient Photo

Take a photo of yourself so the front desk can verify your identity.

4

Signature

The patient signs below
Sign here with your finger

By signing, you attest to the accuracy of the information provided.

By signing, you consent to Ability and Empowerment Services collecting and processing the information above, including your photograph and signature, for the purpose of this visit, handled in accordance with the and the HIPAA Privacy Rule.

Personal data is processed in accordance with our privacy policy and applicable regulations. It will never be shared with third parties without explicit consent.
Ability and Empowerment Services · 1 N Charles St, Baltimore, MD 21201 · (443) 438-5538

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Filing the signed record

Preparing the signed document. Please keep this page open.

Sign-in recorded

The signed record has been filed.

Reference—

Privacy Notice

What we collect

The patient's name, phone number, optional email address, the reason for the visit, where and how long the meeting lasted, a photograph of the patient and the staff member together, both signatures, and the geographic location at which this record was signed.

Why we collect the location

The location is recorded once, at the moment of signing, as part of the signed record. It establishes where the meeting took place. It is not used to track anyone, and it is not collected at any other time.

How it is kept

The signed record is stored in the private files of Ability and Empowerment Services and is treated as protected health information under the HIPAA Privacy Rule. It is never sold, and never shared with third parties without explicit consent.

Your rights

You may ask to see, correct or delete your record at any time by contacting the practice at (443) 438-5538.

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