Consent to HIPAA

Your typed name below will act as your signature and acceptance of this form.

Consent to Health Insurance Portability Accountability Act (HIPAA):

I have received the HIPAA notice form as described on this link. Click here to read HIPAA Disclosure.

I have read and understand the Health Insurance Portability Accountability Act (HIPAA) Client / Patient Rights & Therapist Duties.

Type full patients name (required)

Patient Electronic Signature (type name) (required)

Date (required)

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