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 (949) 753-3330.

 If you have any questions about my Notice of Privacy Practices, please contact me at: 1151 Dove St., Ste. 105, Newport Beach, Ca. 92660. You may also call me at (949)753-3330.

I acknowledge receipt of the Notice of Privacy Practices of Dorothy Miyaoka, LMFT.