Acknowledgment of Notice of Privacy Practices

Foundation Psychiatry, P.C. -- 35 Collier Road NW, Suite 425, Atlanta, GA 30309 -- Tel: (404) 902-6184 | Fax: (404) 400-1952

Effective Date: [09/17/2026] | Version: 1

Patient First Name

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Patient Last Name

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Acknowledgment of Notice of Privacy Practices

By signing below, I acknowledge that I received Foundation Psychiatry, P.C.'s Notice of Privacy Practices.

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By submitting your signature, the parties agree that this agreement may be electronically signed. The parties agree that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

Patient Name (Print)

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Date

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Relationship to Patient (if applicable)

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For Internal Use Only

Name of Employee Receiving Acknowledgment (Print)

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Date

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If applicable, reason patient's written acknowledgment could not be obtained:

Patient was unable to sign

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Patient refused to sign

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Other

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