RECEIPT OF NOTICE OF PRIVACY PRACTICES

I hereby acknowledge that I have received a copy of the Notice of Privacy Practices from Carl Grody, LISW-S. I understand this document provides information on how my health information may be used or disclosed by Carl Grody, LISW-S, and my rights with respect to my health information.

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Signature of Patient/Legal Representative Date

If signed by a legal representative, relationship to patient

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