6. HIPAA AOR FORM 6. HIPAA AOR ACKNOWLEDGMENT OF RECEIPT OF PROVIDER'S NOTICE OF PRIVACY PRACTICES I acknowledge that I have received a copy of KW Counseling Services, LLC Notice of Privacy Practices which summarizes the ways my identifiable health information may be used and disclosed by this Provider and states my rights with respect to my medical information. I understand this Provider has the right to revise these information practices and to amend the Notice of Privacy Practices. I have been informed that in the event this Provider revises its information practices, a revised Notice will be posted at 2219 229th Place, Ames Iowa 50014, and that I may obtain a current Notice of Privacy Practices at any time from KW Counseling Services, LLC. Signature of Patient or Guardian / Representative - HIPAA AOR Form * signature keyboard Clear Today's Date * If Guardian/Representative- State Relationship to Patient Signature of Witness * signature keyboard Clear Today's Date * reCAPTCHA If you are human, leave this field blank. Submit Δ Contact Me TODAY. I'D LOVE TO HEAR FROM YOU. *I am not currently accepting new clients but can add you to our waiting list. Contact Us Full Name * Phone Number * Email * Reason for Contacting (Select One) * General QuestionHelp With FormsNew Client Inquiry (Add Me to Waiting List)Other Reason for Contacting (Select One) Message * reCAPTCHA If you are human, leave this field blank. Submit Δ
