Notice Of Privacy Practices

Notice Of Privacy Practices
By signing this receipt, I acknowledge I was given a copy of the Raleigh Therapy Services, Inc.’s HIPAA Notice of Privacy Practices to review.

I understand that at any time I may request a copy of the HIPAA Notice of Privacy Practices be provided to me. Additionally, I understand that the I may access the Privacy Practices at any time at the following website: www.raleights.com/wp-content/uploads/2013/10/RTSPrivacy-Practices-Oct-2013.pdf
Child's Name *
Signature of Parent/Guardian *
Name of Parent/Guardian *

First Name Last Name
Date

- Month - Day Year
Date
Should be Empty: