Patient’s Acknowledgement of Receipt of Notice of Privacy Practices

Please sign, print your name, and date this acknowledgement form.

I have been provided a copy of Kyla Care, LLC Notice of Privacy Practices.”

We have discussed these policies, and I understand that I may ask questions about them at any time in the future.

I consent to accept these policies as a condition of receiving mental health services. This electronic signature in lieu of a physical signature acknowledges receipt  and agrees to the conditions within the policy.