HIPAA Privacy Notice Acknowledgment
Please complete this form to acknowledge receipt of the Notice of Privacy Practices from Destination Little Learners ABA Services.
Client Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
I acknowledge that I have received or been offered a copy of the Notice of Privacy Practices for Destination Little Learners ABA Services. HIPAA Privacy Notice is available on DLL website for referrence. I understand that this Notice may be updated and that I may request a copy at any time.
*
I acknowledge and agree
Signature of Client / Parent / Legal Guardian
*
Printed Name
*
First Name
Last Name
Relationship to Client
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit Acknowledgment
Submit Acknowledgment
Should be Empty: