NOTICE OF PRIVACY PRACTICE ACKNOWLEDGEMENT
I have received, read, and understood the Noce of Privacy Pracces. I understand that Kids Express
Speech Therapy has the right to change its Noce of Privacy Pracces from me to me and that I
may contact this organizaon to obtain a current copy of the Noce of Private Pracces.
I, ______________________________________, conrm that I have been given a copy of the Noce of
Privacy Policy.
Client name: ________________________________________________
Client D.O.B: ___________________
Parent/Guardian Name: ________________________________________
Parent/Guardian Signature: _______________________________________
Date: ___________________
Oce use only
I aempted to obtain the paent’s signature in acknowledgement of this Noce of Privacy of Pracces
Acknowledgement, but was unable to do so as documented below.
Date: _____________ Inials: _______________ Reason: ______________________________