HIPAA Notice and Consent Form

HIPAA Notice of Receipt of Privacy Practices (Page 7 of 7)

• I acknowledge that I have been informed about the Notice of Privacy Practices for Stable Transformation LLC
• I understand that the Notice of Privacy Practices discusses how my protected health information (PHI) may be used and/or disclosed, my rights with respect to protected health information, and how and where I may file a privacy related complaint.
• I may review a copy of this Notice and I have been offered a copy from the therapist.

Consent for Treatment: I have read and thoroughly understand this document. I have read the Privacy Policy information and understand the therapist’s responsibility to make such decisions when necessary. By signing, I give consent to receive ongoing outpatient treatment at Stable Transformation, LLC. I have read and agree to the terms of this agreement).

By clicking the "I Accept" button, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual signature on this Agreement. By selecting "I Accept" you consent to be legally bound by this Agreement's terms and condition.

* Indicates required field

Name *

First

Last

Date of Birth (00/00/00) *

Name of Parent/Guardian if Client is Minor *

First

Last

Today's Date (00/00/00) *

Name (ESignature) *

I Accept