You may refuse to sign this acknowledgement and authorization. In refusing, we may not be allowed to process requests for information.
The undersigned acknowledges opportunity to review and/or receive a copy of the currently effective
Notice of Privacy Practices for Social Skills for Life. A copy is available in the office upon request and on our website. A copy of this signed, dated document shall be as effective as the original.
PLEASE LIST ANY OTHER PARTIES WHO CAN HAVE ACCESS TO YOUR HEALTH INFORMATION:
(This includes step-parents, grandparents, and any care takers who can have access to this patient’s records)