Ingrid Oliansky, Licensed Marriage and Family Therapist
MFC# 48975
Call for an appointment (818) 927-3855
Acknowledgement of Receipt of Privacy Practices
By signing this form, you acknowledge receipt of the Notice of Privacy Practices that I have given to you. My Notice of Privacy Practices provides information about how I may use and disclose your protected health information. I encourage you to read it in full.
My Notice of Privacy Practices is subject to change. If I change my notice, you may obtain a copy of the revised notice from me by contacting me at (818) 927-3855
If you have any questions about my Notice of Privacy Practices, please contact me at:
18034 Ventura Blvd., #174
Encino, CA 91316-3516
(818) 927-3855
I acknowledge receipt of the Notice of Privacy Practices of Ingrid Oliansky, LMFT
Name:
Date:
