Notice Of Privacy Practices Form Andrews Center

NOTICE OF PRIVACY PRACTICES

Client Name: _______________________________________

Case No: _______________________________

ANDREWS CENTER BEHAVIORAL HEALTHCARE SYSTEM

Acknowledgement of Receipt of Notice of Privacy Practices

Andrews Center wants you to be informed of your rights to privacy and confidentiality. To further this

purpose, you have been provided with a copy of Andrews Center Notice of Privacy Practices.

You are requested to sign the acknowledgement below and return it to Andrews Center at:

P.O. Box 4730, Tyler, Texas 75712 to document your receipt of this notice.

Thank you for your assistance.

I have received a copy of the Notice of Privacy Practices of Andrews Center.

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Date

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