HIPAA Acknowledgement Notice | Leap of Language

Leap of Language Inc.

37171 Sycamore Street Apt. 633, Newark, CA 94560

205-534-4330

Acknowledgement That You Have Received Our HIPAA Privacy Notice

Leap of Language Inc. is required by law to keep your health information and records safe.

This information may include:

• Notes from your doctor, teacher or other healthcare provider

• Medical history

• Test results

• Treatment notes

• Insurance information

We are required by law to give you a copy of our privacy notice. This notice tells you how your health information maybe used and shared.

I acknowledge that I have received a copy of Leap of Language Inc.'s HIPAA Notice of Privacy Practices that fully explains the uses and disclosures they will make with respect to my individually identifiable health information.

I have had the opportunity to read the notice and to have any questions regarding the notice answered to my satisfaction

I understand Leap of Language Inc. cannot disclose my health information other than as specified in the notice

I understand that Leap of Language Inc. reserves the right to change the notice and the practices detailed therein if it sends a copy of the revised notice to the address I have provided.

Signature of Client or Legal Representation

Relationship to Client

Please Note: It is your right to refuse to sign this Acknowledgement

Office Use Only

I tried to obtain written Acknowledgement of our Privacy Notice by the patient/legal representative noted above.

It could not be obtained for the following reason(s)

• An emergency prevented us from obtaining acknowledgement.

• The individual was unwilling to sign.

• A communication barrier prevented us from obtaining acknowledgement.

Other

Staff Member Signature

Date

Leap of Language Inc.

37171 Sycamore Street Apt. 633, Newark, CA 94560

stcin001@gmail.com

205-534-4330

Acknowledgement That You Have Received Our HIPAA Privacy Notice

Please Note: It is your right to refuse to sign this Acknowledgement