Form

( This acknowledgelnent is intended for all our active, present clients; Active, present clients are those clients admitted to Neubauer Hyperbaric Neurologic Center prior to April 1, 2003; This form should be completed by the parent or legal guardian who signed Form PS-02 during initial admission.)

I acknowledge that I have received a copy of Neubauer Hyperbaric Neurologic Center.

"Notice of Privacy Practices."

I understand that this notice will be filed with my child's health information record.

I know this "Notice of Privacy Practices" is effective April 14, 2003.

Recipient Name*

Date of Birth*

Parent or Legal Guardian Signature*

Date*

Company Representative SignatureTitle*

Date*