Notice of Privacy Practices Acknowledgment Notice of Privacy Practices Acknowledgment Form Patient Name” * I HAVE RECEIVIED A COPY OF THE HOPE CLINIC AND CARE CENTER, INC. PATIENT RIGHTS AND RESPONSIBILITIES FORM AND THE HOPE CLINIC AND CARE CENTER’S NOTICE OF PRIVACY PRACTICES. I AUTHORIZE THE HOPE CLINIC & CARE CENTER TO LEAVE VOICEMESSAGES AND/OR TEXTS TO MY MOBILE PHONE. * If minor, enter Parent/Guardian Name above: 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 Acknowledgment: * Clear Date: * reCAPTCHA Submit If you are human, leave this field blank.