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Acknowledgement That You Have Received Our HIPAA Privacy Notice
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Branched Out Therapy, Inc., is required by law to keep your health information and records safe.
This information may include:
Notes from your doctor, teacher or other healthcare provider
Medical history
Test results
Treatment notes
Insurance information
We are required by law to give you a copy of our privacy notice. This notice tells you how your health information maybe used and shared.
I acknowledge that I have received a copy of Branched Out Therapy, Inc. HIPAA Notice of Privacy Practices that fully explains the uses and disclosures they will make with respect to my individually identifiable health information.
I have had the opportunity to read the notice and to have any questions regarding the notice answered to my satisfaction.
I understand Branched Out Therapy, Inc. cannot disclose my health information other than as specified in the notice.
I understand that Branched Out Therapy, Inc. reserves the right to change the notice and the practices detailed therein if it sends a copy of the revised notice to the address I have provided.
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