I, __________________________________________________, hereby acknowledge receipt of
                            Patient Name
UROLOGY SPECIALISTS, S.C.'s Notice of Privacy Practices. The Notice of Privacy Practice provides detailed information about how UROLOGY SPECIALISTS, S.C. may use and disclose my confidential information.

I understand that the physician has reserved a right to change his or her privacy practices that are described in the Notice. I also understand that a copy of any Revised Notice will be provided to me or made available.

If you are not the patient, please specify your relationship to the patient ___________________.

- Patient's file