ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
By signing this form, you acknowledge receipt of the Notice of Privacy Practices that I have given to you. My Notice of Privacy Practices provides information about how I may use and disclose your protected health information. I encourage you to read it in full.

My Notice of Privacy Practices is subject to change. If I change my notice, you may obtain a copy of the revised notice from me by contacting me at (619) 624-0735.

If you have any questions about my Notice of Privacy Practices, please contact me at therapy@pamelahollings.com or (619) 624-0735.
I acknowledge receipt of the Notice of Privacy Practices of Pamela Hollings, LCSW.
Signature (patient/parent/conservator/guardian): *
Type your name here for your consent to use this information.
Date: *
MM
/
DD
/
YYYY
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy