HIPAA Privacy Policy Acknowledgement

Please do not have your parents sign any of the forms. If they are obtaining legal guardianship for you after your 18^th birthday, we have a different process. Those court documents can be submitted to us via fax to our privacy department at 920-882-0857.
If you are still 17, please wait to sign the documents until your 18^th birthday. They will be invalid if they are signed/dated prior to your birthday.
Please reach out to us if you have any questions about this process or need help with the forms. Our call center hours are Monday – Friday, 8:00-4:30 and out phone number is 920-750-7000.

– HIPAA Privacy Policy Acknowledgement –

"*" indicates required fields

Click here to view Catalpa Health’s Notice of Privacy Practices

By signing this form, you acknowledge that we (Catalpa Health, Inc.) have given you a copy of our Notice of Privacy Practices, which explains how your health information will be handled by us in various situations. We are required under law to ask you to sign this document on the first day we provide health care services to you, whether in person or via electronic media. If your first day of service with us is due to an emergency, we will give you our Notice of Privacy Practices, and ask you for your signature acknowledging receipt of it as soon as we can after the emergency.

First Name of Client*

Last Name of Client*

Client Date of Birth*

Signature of Client*

I acknowledge that I have received Catalpa Health, Inc.’s Notice of Privacy Practices.

Signature of Client (if age 14 or older)
I acknowledge that I have received Catalpa Health, Inc.’s Notice of Privacy Practices.

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