Receipt of HIPPA

Receipt of HIPAA

Family Connections, LLC
1643 Warwick Avenue, #200, Warwick RI 02889
Phone: 401-952-8188
Fax: 401-385-9410
familyconnections@familyconnectionsri.com
familyconnectionsri.com

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

We 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 *

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Last

Date of Birth *

I have been given a copy of Family Connections, LLC privacy notice. *

Signature Signature of client/Legal representative (if necessary) *

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I gave a copy of this privacy notice to

He/she declined to sign for it.

Date

Client/legal representative (if necessary):

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Clinician's Signature

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Clinician's Email *

Date