Patient Privacy Acknowledgment

Acknowledgement: Receipt of Privacy Practices Notice
Client Name:

First NameLast Name
My signature below indicates that I have received a copy of the Vermont Center for Anxiety Care’s Notice of Privacy Practices.
Client Signature:

Clear
Date:

MonthDayYear
Date
Legal Guardian:

First NameLast Name
Legal Guardian Signature:

Clear
Date:

MonthDayYear
Date
Provider's Name: _______________________________________________________

Provider's Signature: ____________________________________________________

Date: ________________________________________________________________
Should be Empty:

Acknowledgement: Receipt of Privacy Practices Notice