Notice Of Privacy Practices Acknowledgement Form - Florida Department Of Health
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1Rick Scott
:
Mission
Governor
To protect, promote & improve the health
of all people in Florida through integrated
Celeste Philip, MD, MPH
state, county & community efforts.
Surgeon General and Secretary
Vision: To be the Healthiest State in the Nation
State of Florida
Department of Health
Notice of Privacy Practices Acknowledgement Form, DH 150-741, 09/13
Name _______________________________________ Client ID:__________________________
Facility/Site/Program: Florida Department of Health in Volusia County Dental
I have received a copy of the DOH Notice of Privacy Practices Form DH 150-741, 09/13.
Signature: ________________________________________ Date: ________________________
Individual or Representative with legal authority to make health care decisions
If signed by a Representative:
Print Name: ________________________________________ Role:________________________
(Parent, guardian, etc.)
Witness: ___________________________________________Date: _______________________
If the individual has a representative with legal authority to make health care decisions on the individual’s behalf, the notice
must be given to and acknowledgement obtained from the representative. If the individual or representative did not sign above,
staff must document when and how the notice was given to the individual, why the acknowledgement could not be obtained,
and the efforts that were made to obtain it.
Notice of Privacy Practices given to the individual on: Date:______________
___Face to face meeting
___Mailing
Reason Individual or Representative did not sign this form:
___Email
_____Individual or Representative chose not to sign
___Other
_____ Individual or Representative did not respond after more than one attempt
_____Email receipt verification
_____Other
Good Faith Efforts: The following good faith efforts were made to obtain the individual’s or Representative signature. Please
document with detail (e.g., date(s), time(s), individuals spoken to and outcome of attempts) the efforts that were made to
obtain the signature. More than one attempt must have been made.
_____Face to face presentation(s)_________________________________________________________________________
_____Telephone contact(s)______________________________________________________________________________
_____Mailings_________________________________________________________________________________________
_____Email___________________________________________________________________________________________
_____Other___________________________________________________________________________________________
Staff Signature____________________________________________________ Title:_______________________________
Print Name:______________________________________________________ Date:_______________________________
This form must be retained for a period of at least six years in the appropriate record.
Florida Department of Health
in Volusia County • Dental Office
1845 Holsonback Dr., • Daytona Beach, FL 32117-5114
PHONE: 386-274-0895 • FAX: 386-274-0894
Volusia.FloridaHealth.gov
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