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.
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.