Acknowledgement of Privacy Notice

First Name(Required)

Last Name(Required)

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This is to confirm that I have received the NOTICE OF PRIVACY PRACTICES concerning Protected Health Information from the Neighborhood Counseling Center. This has provided me with information regarding how my Protected Health Information can be used and disclosed by the Neighborhood Counseling Center in accordance with the Health Insurance Portability and Accountability Act.

Full Name (electronic signature)(Required)

If client is under 18, a parent or guardian must sign to provide authorization

Date(Required)

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Acknowledgement of Privacy Notice

Acknowledgement of Privacy Notice

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