cobb
SPEECH & LANGUAGE SERVICES
Privacy Notice Acknowledgement
Patient Name
First Name
Last Name
Date of Birth:
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Month
-
Day
Year
Date
I hereby acknowledge that I have reviewed a copy of Cobb Speech and Language Notice of Privacy Practices. This notice describes how medical information about me (or above mentioned patient) may be used and disclosed, and how I can access this information.
I understand that:
I have the right to review the HIPPA Statement before signing this acknowledgment.
Cobb Speech and Language Services reserves the right to change its privacy practices and the terms of its Notice of Privacy Practices at any time.
A current copy of this notice is always available upon request.
Additional Persons Authorized to have access to the patient listed above health records
Parents/Legal Guardians:
Other Family Members:
Other(s)
Persons or entities not entitled to have access to the patient listed above health records
Parent/Guardian Signature:
Date:
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Month
-
Day
Year
Date
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