Child Client Intake Form (Page 7 of 8) in pdf

HOPE COUNSELING CENTERS

Phone: (863) 292-8292

Winter Haven Office

Fax: (863) 292-8283

160 Ave E., N.W.

Winter Haven, FL 33881

ACKNOWLEDGEMENT OF RECEIPT

OF SUMMARY NOTICE OF PRIVACY PRACTICES

Our Notice of Privacy Practices provides information about how we may use and disclose protected health information about

you. The notice contains client rights section describing your rights under the law. You have the right to review our Notice

before signing this Consent. The terms of our Notice may change. If we change our Notice, you may obtain a revised copy by

contacting our office at (863) 709-8110.

You have the right to request that we restrict how protected information about you is used or disclosed for treatment,

payment or health care operations. We are not required to agree to this restriction, but if we do, we shall honor that

agreement.

By signing this form you consent to our use and disclosure of protected health information about you for treatment, payment

and health care operations. You have the right to revoke the Consent in writing, signed by you. However, such a revocation

shall not affect any disclosures we have already made in reliance on your prior Consent. Hope Counseling Centers provides

this form to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

The client understands that:



Protected health information may be disclosed or used for treatment, payment or health care operations.



Hope Counseling Centers has a Notice of Privacy Practices and that the client has the opportunity to review this

notice.



Hope Counseling Centers reserves the right to change the Notice of Privacy Practices.



The client has the right to request restrictions to the uses of their information but Hope Counseling Centers does not

have to agree to those restrictions.



The client may revoke this Consent in writing at any time and full disclosures will then cease.



Hope Counseling Centers may condition receipt of treatment upon the execution of this consent.

I have received a copy of the Summary Notice of Privacy Practices. I understand that I may also request a copy of the

practice’s complete Notice of Privacy Practices if I so desire.

Name of Client or Guardian (print)

Signature of Client or Guardian

Date

Offices:

Lakeland | Winter Haven | Daytona | Tampa

Child Client Intake Form Page 7