Client Acknowledgment | WellTrust Home Care LLC

This form acknowledges that you have received or been offered a copy of the Notice of Privacy Practices for WellTrust Home Care LLC.

Acknowledgment Statement

I acknowledge that I have received or been offered a copy of the Notice of Privacy Practices for WellTrust Home Care LLC. I understand that this notice describes how my personal and health-related information may be used and disclosed, and how I can access this information.

Print & Sign

Please print this page, complete the information below, and return to WellTrust Home Care LLC.

Client Name (Print)

Signature

Date

If signed by personal representative:

Representative Name (Print)

Relationship to Client

Representative Signature

Date

Electronic Signature

Complete the form below to submit your acknowledgment electronically.

Client Name *

Email Address *

Phone Number

I acknowledge that I have received or been offered a copy of the Notice of Privacy Practices. I understand my rights regarding my personal and health-related information.

Electronic Signature (Type Full Legal Name) *

Date *

By typing my name above, I understand that this constitutes a legal signature confirming that I acknowledge receipt of the Notice of Privacy Practices.

Contact

Email: welltrusthomecare@gmail.com

Phone: (234) 704-6458

Mailing Address:
8210 Macedonia Commons Blvd, Suite 3B PMB 1080
Macedonia, OH 44056

Client Acknowledgment of Privacy Practices

Acknowledgment Statement

Print & Sign

Electronic Signature

Contact

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