Signature-Page-Acknowlegement-of-Receipt

Dr. Debra Mandel-A Professional Psychological Corporation
Service Provider: Debra Mandel, Ph.D.
License #PSY11225
818.335.6309
drdebra@dmdoc.com www.drdebraonline.com

Acknowledgment of Receipt of Office Policies/Consent for Treatment (OPCT)
By signing below, I agree to all the terms set forth in the OPCT form.
Patient's Name*

First NameLast Name
Patient's Signature*

Clear
Date*

MonthDayYear
Acknowledgement of Receipt of Telehealth Disclosure (THD):
Patient's Name*

First NameLast Name
Patient's Signature*

Clear
Date*

MonthDayYear
Acknowledgement of Receipt of Notice of Privacy Practice (HPP):
I, (patient), have received a copy of this Office's Notice of Privacy Practices.*

First NameLast Name
Patient's Name*

First NameLast Name
Patient's Signature*

Clear
Date*

MonthDayYear
Please verify that you are human*
It is your right to refuse to sign this document

For Office Use Only:

The reason that a standard acknowledgment (such as the above) of the receipt of the Notice of Privacy Practices was not obtained:

_________ Patient refused to sign.

_________ Communication barriers prohibited obtaining the acknowledgement.

_________ An emergency situation prevented this office from obtaining it. </>

_________Others:_____________________________________________________

(Form-Signature Page)
Should be Empty: