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

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.

Signature of Client or Legal Representation

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.

Staff Member Signature

© 2020 by PIMM-USA. Proudly created for Leap Of Language Inc.

Speech Therapy in Newark | Language Therapy in Newark | Pediatrics 94560

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