HIPAA Privacy Policy Acknowledgement

**Please note, if the client is 14 -17 years old they need to sign these documents with their parent/legal guardian.  Clients 18 or older should sign independently, without their parent/legal guardian)**

HIPAA Privacy Policy Acknowledgement

"*" indicates required fields

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.

Contact Number:*

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.

First Name of Client*

Last Name of Client*

Client Date of Birth*

Indicate your relationship to the client:*

Make SelectionParentLegal GuardianPower of Attorney/Delegated RepresentativeSelf (client 18+)Other (must be approved by Catalpa's Privacy Department)

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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