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Young Women with Backpacks

Receipt of Privacy Practice Information

Please read and sign the form below.

Receipt of Privacy Practice Information

Our Notice of Privacy Practices provides information about how we may use and disclose protected health information about you. As provided in our Notice, the terms of our Notice may change. If we change our Notice, you may obtain a revised copy by contacting House of Hope for Girls Program at 1040 Boulevard SE, Suite M, Atlanta, GA 30312 or (470) 344-4905.

By signing below, you acknowledge that you have received a copy of our Notice of Privacy Practices on the date indicated below.

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