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HIPAA Consent

Review and acknowledge the terms of your treatment plan as part of our commitment to informed care.

HIPAA Consent

Review and acknowledge the terms of your treatment plan as part of our commitment to informed care.

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Printed Name of Patient Date
Month
Day
Year

I acknowledge that I have received and read the HIPAA Notice of Privacy Practices from Relationship Clinics. I understand that this notice explains how my health information will be used and protected.

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