We at Building Bridges Through Communication have and always will be concerned with protecting your privacy, especially in matters concerning your personal and/or health information. In accordance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA), we are required to supply you with a copy of our privacy practices. You have the right to review that notice before you sign this acknowledgement form (§ 164.520). We encourage you to read this document carefully, for it outlines the limitations of the use and disclosure of your personal and/or health information as well as your rights as a patient. If you ever have any questions or concerns regarding the use or disclosure regarding your personal and/or health information we would be happy to address them.

I acknowledge that I have received a copy of the Building Bridges Through Communication Notice of Privacy Practices for Protected Health Information.