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Appendix 8

Client Rights and Responsibilities Acknowledgement

Active clinic: [Company]

Use this form to document that the client and, when applicable, the parent or legal guardian have received and reviewed the Client Rights and Responsibilities. Signing confirms that the client understands the rights and responsibilities described in that document.

Acknowledgement Statement

I acknowledge that I have received and reviewed the Client Rights and Responsibilities. I understand my rights and responsibilities as a client of the [Company], including the right to file a complaint, the right to participate in my treatment, the right to privacy under HIPAA and applicable Florida laws, and my responsibility to follow clinic policies and provide accurate information.

Office Director Contact for Rights Concerns

Client Acknowledgement
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Staff Witness
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