Notice of Privacy Practices

Acknowledgment of receipt

Please read the Notice of Privacy Practices, then sign below. Signing only confirms that you received the notice. It does not affect your care.

I acknowledge that I have received, or been offered, a copy of the Notice of Privacy Practices of Lisa Jimenez PMHNP PLLC. The notice explains how my health information may be used and shared, and what my rights are.

Patient name (print)

Signature

Date

If signed by a personal representative: name and relationship to patient

For practice use only

Notice effective date: October 10, 2026

If an acknowledgment could not be obtained, record the date of the attempt and the reason: