Notice Acknowledgement
Download a blank fillable Notice Acknowledgement in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Notice Acknowledgement with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1Fill out the following form, then click the 'Save
Form' button to save the form to your
computer. If using Google Chrome, right-click
the form and select 'Save As...' Send the form
in an email to the following address:
.
N OTICE ACK NOW L ED G EM EN T
Purpose: This form is used to document a patient’s acknowledgement of receipt of our Privacy Practices or our
good faith, but unsuccessful effort to obtain that acknowledgement. We are not obligated to attempt to obtain
this acknowledgement in an emergency treatment situation.
PATIENT NAME: ___________________________________________________
TO THE INDIVIDUAL: Please complete the following acknowledgement.
I acknowledge that I received the Privacy Practices Notice this health care provider.
(Please sign in the space indicated below).
If the individual refused or was unable to sign an acknowledgement that the individual received our Privacy
Practices Notice, please check appropriate box below. Describe your good faith effort to obtain the individual’s
signed acknowledgement and the reason you were unsuccessful.
Individual refused or was unable to sign an acknowledgement that the individual received our Privacy Practices
Notice.
Individual received our Privacy Practices Notice in connection with an emergency treatment situation.
We are, therefore, not required to obtain an acknowledgement.
THIS FORM HAS BEEN SIGNED BY: (please check one)
PATIENT
PATIENT’S REPRESENTATIVE
I attest that the above information is correct.
______________________________________________
___________________
Signature
Date
______________________________________________
Printed Name
______________________________________________
Witness signature
Print Form
Reset Form
Save Form
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business