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For Clients & Families

HIPAA Privacy Policy Acknowledgement

  • By signing this form, you acknowledge that we (Catalpa Health, Inc.) have given you a copy of our Notice of Privacy Practices, which explains how your health information will be handled by us in various situations. We are required under law to ask you to sign this document on the first day we provide health care services to you, whether in person or via electronic media. If your first day of service with us is due to an emergency, we will give you our Notice of Privacy Practices, and ask you for your signature acknowledging receipt of it as soon as we can after the emergency.
  • In the event that there is an error with form submission, we will need to contact you directly. Please provide the best phone number to reach you if follow up is needed.
  • I have received Catalpa Health, Inc.’s Notice of Privacy Practices.
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