Leap of Language Inc.
37171 Sycamore Street Apt. 633, Newark, CA 94560
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.