Notice Of Privacy Practices Acknowledgement Page 3

DSHS NOTICE OF PRIVACY PRACTICES FOR CONFIDENTIAL INFORMATION

Effective September 23, 2013

Acknowledgement

(Needed when DSHS provides direct health care treatment)

CLIENT NAME

CLIENT DATE OF BIRTH

I have received a copy of the DSHS Privacy Notice and have had a chance to ask questions about how DSHS will

use and share my Personal Health Information.

CLIENT OR PERSONAL REPRESENTATIVE SIGNATURE

DATE

FOR DSHS USE ONLY

To be completed if unable to obtain signature of client or personal representative.

Describe efforts made to have the client acknowledge receipt of the Notice of Privacy Practices (NPP):

Describe reason why acknowledgement was not obtained:

STAFF MEMBER’S NAME AND TITLE (PLEASE PRINT)

ADMINISTRATION/DIVISION

STAFF’S SIGNATURE

DATE

DSHS 03-387 (REV. 04/2014)

0 votes

Parent category: Legal