Submit - Pelican Therapy Partners

Acknowledgement that you have received our HIPAA Privacy Notice

Client Name

Pelican Therapy Partners is required by law to keep your health information and records safe.

This information may include:

• Notes from your doctor, teacher or other healthcare provider

• Medical history

• Test results

• Treatment notes

• Insurance information

We are required by law to give you a copy of our privacy notice. This notice tells you how your health information may be used and shared.

I acknowledge that I have received a copy of Pelican Therapy Partners HIPAA Notice of Privacy Practices that fully explains the uses and disclosures they will make with respect to my individually identifiable health information.

I have had the opportunity to read the notice and to have any questions regarding the notice answered to my satisfaction.

I understand Pelican Therapy Partners cannot disclose my health information other than as specified in the notice.

I understand that Pelican Therapy Partners reserves the right to change the notice and the practices detailed therein if it sends a copy of the revised notice to the address I have provided.

Parent/Guardian Name

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