HIPAA Privacy Policy Acknowledgement

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Click here to view Catalpa Health's Notice of Privacy Practices

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.

First Name of Client*

Last Name of Client*

Client Date of Birth*

Indicate your relationship to the client:*

Name of Parent/Legal Guardian*

Signature of Parent/Legal Guardian*

I acknowledge that I have received Catalpa Health, Inc.’s Notice of Privacy Practices.

Signature of Parent/Legal Guardian
I acknowledge that I have received Catalpa Health, Inc.’s Notice of Privacy Practices.

Signature of Client (if age 14 or older)

I acknowledge that I have received Catalpa Health, Inc.’s Notice of Privacy Practices.

Signature of Client (if age 14 or older)
I acknowledge that I have received Catalpa Health, Inc.’s Notice of Privacy Practices.

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HIPAA Privacy Policy Acknowledgement

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