NOTICE OF PRIVACY PRACTICES
Effective Date: April 1, 2003



I ___________________________________________ received a copy of the InterCommunity Mental Health Group, Inc. Client Privacy Notice this date.

 
______________________________________________________________________
Client Name

 		Date

 
______________________________________________________________________
Employee Name

 		Date

 
Special Notes:

____   Translator required
____   Client chose not to sign
____   Other:

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

Place in Clinical Record – Section: Outgoing

You will not be retaliated against for filing a complaint.


 
      If you believe InterCommunity Mental Health Group has violated your
privacy rights, you may file a complaint or contact the

Department of Health and Human Services
Region I – Office of Civil Rights
J.F.K. Federal Building
Room 1875, Boston MA 02203