ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

By signing this form, you acknowledge receipt of the Notice of Privacy Practices that I have given to you. My Notice of Privacy Practices provides information about how I may use and disclose your protected health information. I encourage you to read it in full.

My Notice of Privacy Practices is subject to change. If I change my notice, you may obtain a copy of the revised notice from me by contacting me at (619) 624-0735.

If you have any questions about my Notice of Privacy Practices, please contact me at therapy@pamelahollings.com or (619) 624-0735.

I acknowledge receipt of the Notice of Privacy Practices of Pamela Hollings, LCSW.

Signature (patient/parent/conservator/guardian): *

Type your name here for your consent to use this information.

Date: *

YYYY

Submit

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms