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Hill Country Speech Therapy, PLLC
RECEIPT OF NOTICE OF CLIENT PRIVACY PRACTICES
This document acknowledges that you have received a copy of: 1. Notice of Client Privacy Practices
This document is not a contract, authorization, release, or consent form. This document will remain in your records.
From time to time we apprise our clients of events that may be of interest to them via email or mail. Please check here if you do NOT wish to be notified of such events.
I, __________________________________, acknowledge that I have received a copy of the Notice of Client Privacy Practices.
Date: _______ / _______ / _____________ Parent or Legal Guardian Date
Relationship to Client: _____________________________________________
rev. May. 2013 Receipt of Notice of Client Privacy Practices