Notice of Privacy Practices

Notice of Privacy Practices

For all Patients, Clients, Students

I have read and understand the Notice of Privacy Practices. I have been able to ask questions about how Synergy Wellness Center may use and disclose my protected health information (“PHI”) to carry out treatment, payment or health care operations, and for the purposes that are permitted or required by law. I also have read and understand my rights in regards to my PHI.
When client is a minor, or not competent to give consent, the signature of a parent, guardian, health care agent (proxy), or other representative is required:

Signature of legal representative:

Signature Page in client record. Notice of Privacy Practices to client.