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Hill Country Speech Therapy, PLLC

 12505 Rush Creek Ln, Austin TX 78732 | info@hcspeech.com | (512) 368-2238

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.

Signature: _____________________________________________________

Date: _______ / _______ / _____________ Parent or Legal Guardian Date

Relationship to Client: _____________________________________________

rev. May. 2013 Receipt of Notice of Client Privacy Practices