Receipt of Privacy Practices

Janneta Bohlander & Associates, LLC

Janneta Bohlander, LMFT

83 East Avenue, Suite 208


Janneta Bohlander, LMFT

CT license number 000955

Tax ID 20-3204106

Acknowledgement of Receipt of

Notice of Privacy Practices

Under the provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPPA) we are required to obtain your written acknowledgement of receipt of the Notice of the Privacy Practices.
Bu signing this form, I acknowledge receipt of the Notice of Privacy Practices.


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