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 If you are human, leave this field blank.HIPAA Privacy Notice AcknowledgementOur Notice of Privacy Practices provides information about how we may use and disclose protected health information about you. Your signature below indicates that you have read, understood, and been offered our notice. Signature of Patient or ClientReset SignatureSignature of Parent or Legal GuardianReset SignatureSignature of Legal Representative, if applicableReset SignatureSignature of Employee WitnessReset SignatureRefusalI refuse to sign this formRefusal Comments:Network personnel initialsNote to Network personnel: If person served/representative refuses Notice or signature, initial here Network personnel commentsEmailCaptcha *reCAPTCHA is required.Submit
