rankin children's group | caring for children in brandon
TRANSCRIPT
PRIVACY PRACTICES ACKNOWLEDGEMENT
RANKIN CHILDREN’S GROUP, PLLC
1405 Crossgates Dr. West 151 East Metro, Suite 102
Brandon, MS 39042 Flowood, MS 39232
601-825-0925 601-992-2292
ACKNOWLEDGEMENT FORM
I have received the Notice of Privacy Practices and I have been provided an opportunity to review it.
Name ________________________________________ DOB _____________
(Parent’s Name) (Parent’s DOB)
Signature ______________________________________________________
(Parent’s Signature)
Date ___________________________________________________________