WASHINGTON NOTICE of Privacy Practices Acknowledgement

Melissa McCreery, PhD                                                                       

1201 11th St., Ste 200B   Bellingham, WA 98225  

360.671.8520 / fax 360.715.3657

Paperwork Registration Form Medical History Insurance Information Treatment Goals Acknowledgement

 

I keep a record of the health care services I provide you.  The Washington Notice Form describes in more detail how your health information may be used and disclosed, and how you can access your information.  

By my signature below I acknowledge:

Receipt of the Washington Notice form of Privacy Practices that went into effect April; 13, 2003.

I chose not to receive a copy of the Washington Notice Form of Privacy Practices that went into affect on April 14, 2003. 

Signature of Patient or legally authorized individual  Relationship (self, parent, legal guardian, personal representative)  
Printed Name Date

(Notation, if any, by staff)

                                                                                                                                                           

                                                                                                                                                           

Staff Signature                    Date

This form will be retained in your medical record.