Receipt of HIPPAReceipt of HIPAAFamily Connections, LLC 1643 Warwick Avenue, #200, Warwick RI 02889 Phone: 401-952-8188 Fax: 401-385-9410 [email protected] familyconnectionsri.com Please enable JavaScript in your browser to complete this form.ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICESWe are required by Federal Law to give you this notice and to prove that you received it. You may use your mark, stamp, or signature.Client's Name *FirstLastDate of Birth *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920I have been given a copy of Family Connections, LLC privacy notice. *Signature Signature of client/Legal representative (if necessary) * Clear Signature I gave a copy of this privacy notice toHe/she declined to sign for it.Date Client/legal representative (if necessary): Clear Signature Clinician's Signature Clear Signature Clinician's Email *DateSubmit