PRIVACY PRACTICES ACKNOWLEDGEMENT

RANKIN CHILDREN’S GROUP, PLLC

1405 Crossgates Dr. West 151 East Metro, Suite 102

Brandon, MS 39042 Flowood, MS 39232

601-825-0925 601-992-2292

ACKNOWLEDGEMENT FORM

I have received the Notice of Privacy Practices and I have been provided an opportunity to review it.

Name ________________________________________ DOB _____________

(Parent’s Name) (Parent’s DOB)

Signature ______________________________________________________

(Parent’s Signature)

Date ___________________________________________________________