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HIPAA
(PLEASE PRINT FORM, THEN FILL OUT AND BRING WITH YOU TO YOUR APPOINTMENT. THANK YOU)
I have read and will be given a copy, by request, of the Notice of Private Practices for Carol Van Dyke, Psy.D., and I acknowledge receipt of these documents.
I am a patient of Dr. Carol Van Dyke’s and I understand and I may review the Policies and Procedures Manual for HIPAA compliance to protect my confidential medical information and all processing necessary for my care; at any time.
Patient Name___________________________________________
Signature_______________________________________________ Date_______________
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