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  • Home
  • About
    • Mission
    • History
    • Board of Directors
    • Honorary Spaces
    • Annual Report
    • Contact
  • Programs + Services
    • Clinical Services >
      • Occupational Therapy
      • Speech Therapy
      • Audiology Services >
        • Auditory Processing
        • Workshops
        • Auditory Interventions >
          • JIAS
          • CAPDOTS
          • Acoustic Pioneer
      • Vision Services >
        • OptomEYES Vision Therapy
      • Client Forms >
        • Health History Form
        • Insurance and Service Authorization
        • Medical ROI
        • Education ROI
        • Rights & Responsibilites
        • Cancellation Policy
        • Notice of Privacy Practices Form
        • Photo Release
      • Insurance Payers
      • Teletherapy Services
    • Neuro Integrative Clinic >
      • Treatment Models
    • Neurofeedback >
      • Neurofeedback Rentals
      • Audio-Visual Entrainment >
        • Finding Calm and Focus with AVe
    • Home-Based / PCA's >
      • Get Started
      • Waiver Services
      • Intake Form
    • S.M.A.R.T. / MLRC >
      • S.M.A.R.T. Program >
        • How S.M.A.R.T. Works
        • S.M.A.R.T. at My School
        • S.M.A.R.T. Mentoring
        • Research & Resources
      • Workshops >
        • S.M.A.R.T. Elementary
        • S.M.A.R.T. Pre-K
        • Bridging The Gap
        • Auditory Processing Workshops
        • Hosting a Workshop
        • Graduate Credits
        • Registration Policy
      • S.M.A.R.T. Supplies >
        • Downloads
    • School-Based Services >
      • Third-Party Billing
    • Turnquist Childcare >
      • Curriculum + Assessment
      • Teen Parent Program
    • Summer Programs >
      • Boost-Up Plus
      • Social Motor Works
      • Advanced-Brain Intensives
      • Inquiry Form
  • Events
    • Workshops
    • Partners + Sponsors
  • Store
    • Shipping & Returns
  • Parents
    • Helpful Resources
    • Testimonials
    • Share Your Story
  • News + Media
    • Growing Times
    • S.M.A.R.T. Newsletter
    • Success Stories
    • Photo Release
  • Donate
    • Tribute to Bob DeBoer

Notice of Privacy Practices Form


​Please read the Notice of Privacy Practices Form below. After you have reviewed, please sign and submit the form. If you prefer to fill out a physical form, we invite you to download the Notice of Privacy Practices Form, complete and fax it to us at (612) 706-5555.

​
You may also fill out the form on your computer and upload a completed PDF version in the upload form box below. Please print completed documents for your personal records.
Download Privacy Practices Form
​Please download the Notice of Privacy Practices Form, read, sign and save. You can print it and fax it us a signed copy at (612) 706-5555 or submit by uploading your completed document by using the upload form. Please print completed documents for your personal records.

​Data Privacy
We invite you to visit our Privacy Practices page to review our policies regarding the security of your information. This page describes how medical information about you may be used and disclosed and how you can get access to this information.

Your Personal Health Information (PHI) may be used and disclosed to those who are involved in your care for the purpose of providing, coordinating, or managing your services. This includes consultation with clinical supervisors or other team members. Your authorization is required to disclose PHI to any other care provider not currently involved in your care.
​
If you have questions or need more information, please contact us by calling (612) 789-1236 or email rehabclinic@actg.org.
Our mission is to promote the maximum development of the whole child and adult through ​innovative, individualized and comprehensive brain-centered programs and services.
Location
1800 NE 2nd Street, Minneapolis, MN 55418
(612) 789-1236 / actg@actg.org
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A Chance To Grow is a 501(c)(3) non-profit organization. Gifts are tax-deductible. ACTG does not discriminate on the basis of race, sex, religion, age, disability, sexual orientation, or marital status.
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