Patient Privacy Acknowledgment

Acknowledgement: Receipt of Privacy Practices Notice
My signature below indicates that I have received a copy of the Vermont Center for Anxiety Care’s Notice of Privacy Practices.
Client Name:

First Name Last Name
Client Signature:

Clear
Date:

Month Day Year
Date
Provider's Name _____________________________________________________________

Provider's Signature __________________________________________________________

Date _______________________________________________________________________
For Minors:
I am the legal guardian of blanks and I have received a copy of the Vermont Center for Anxiety Care's Notice of Privacy Practice's.
Legal Guardian:

First Name Last Name
Legal Guardian Signature:

Clear
Date:

Month Day Year
Date
Provider's Name _______________________________________________________

Provider's Signature ____________________________________________________

Date ________________________________________________________________
Should be Empty:

Acknowledgement: Receipt of Privacy Practices Notice