Notice of Privacy Practices Acknowledgment

Patient Name: *

I HAVE RECEIVIED A COPY OF THE HOPE CLINIC AND CARE CENTER, INC. PATIENT RIGHTS AND RESPONSIBILITIES FORM AND THE CLINIC’S NOTICE OF PRIVACY PRACTICES. I AUTHORIZE THE HOPE CLINIC & CARE CENTER TO LEAVE VOICEMESSAGES AND/OR TEXTS TO MY MOBILE PHONE. *

If Minor, Parent/Guardian Name:

I agree that I have the ability to download or review the Hope Clinic’s Notice of Privacy Practices on the Hope Clinic Website (www.hopeclinic.care) which includes the patients rights and responsibilities. *

I authorize the Hope Clinic and Care Center to leave voice/text messages on the phone number(s) I have provided the Clinic.. *

Patient or Parent/Guardian Signature: *

Clear

Date: *

reCAPTCHA