HIPAA Privacy Notice Acknowledgement Please download the Full document for your reference and fill out the form below to submit to our clinic. HIPAA Privacy Notice Acknowledgement Document Signature of Patient or Client Clear Undo Redo Signature of Parent or Legal Guardian Clear Undo Redo Signature of Legal Representative, if applicable Clear Undo Redo Signature of Employee Witness Clear Undo Redo Refusal I refuse to sign this form Network personnel initials Note to Network personnel: If person served/representative refuses Notice or signature, initial here Email Submit
