TARRY HOUSE, INC.

ACKNOWLEDGEMENT OF NOTICE OF

PRIVACY PRACTICES

I HAVE RECEIVED AND HAD AN OPPORTUNITY TO REVIEW AND RECEIVE A COPY OF THE “NOTICE OF PRIVACY PRACTICES”

YES _____

NO _____

REFUSE OR UNABLE TO SIGN: _____________________________________________

c Person Served c Staff c Board Member c Student Intern c Volunteer

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AUTHORIZED REPRESENTATIVE (Title) ______________________________________

DATE: ____________________________________________