Psi Client Information Form (Page 6 of 6) in pdf

Psi Client Information Form Page 6

SYCH

TRATEGIES

INC

Acknowledgment of Receipt of Notice of Privacy Practices

By signing this form, you acknowledge receipt of the Notice of Privacy Practices that PsychStrategies, Inc. has

given you. The Notice of Privacy Practices provides information about how PsychStrategies, Inc. may use and

disclose your protected health information. You are encouraged to read it in full.

The Notice of Privacy Practices is subject to change. If PsychStrategies, Inc. changes its Notice of Privacy

Practices, you may obtain a copy of the revised form from your clinician, from our web site at

or by contacting our main office at (707) 526-8300.

Please discuss any questions about the Notice of Privacy Practices of PsychStrategies, Inc. with your clinician.

I acknowledge receipt of the Notice of Privacy Practices of PsychStrategies, Inc.

_______________________________________________

______________________________

Signature of Client/Guardian

Date

Inability to Obtain Acknowledgment of Receipt of

Notice of Privacy Practices

I made good faith attempts to obtain my client’s acknowledgment of his/her receipt of the Notice of

Privacy Practices of PsychStrategies, Inc., including _________________________________________

(describe good faith attempts)

___________________________________________________________________________________.

However, because of __________________________________________________________________

(reason(s) why acknowledgment was not obtained)

________________________________________________ I was unable to obtain my client’s

acknowledgement.

___________________________________

______________________________

Signature of Clinician

Date

Rev 06.21.07 Times

House/Forms/Client Information

Psi Client Information Form Page 6