I acknowledge by signing below that I have received my Notice of Privacy Practices and Notice of Individual Rights. I, the undersigned, declare that the information provided is true to the best of my knowledge. I understand that any false identification or other knowingly false information provided may result in criminal prosecution. I am aware that I may direct any questions, concerns, or complaints about the privacy practices of Soaring Therapy and Learning Center to the company’s owners at 706-865-6800.

By virtue of this document, I am also giving my consent to Soaring Therapy and Learning Center, Inc. to disclose protected health information for the purposes of treatment, payment, and operations. I understand Soaring Therapy and Learning Center, Inc. may in the course of rendering care to me, disclose personal health information about me to my family, close friends, or any other person that I identify as long as the information disclosed is relevant to their involvement in my care or the payment for my care. I understand that I may opt-out or otherwise restrict the disclosure of my information to such persons by providing notice to Soaring Therapy and Learning Center, Inc.