Hippa Training Acknowledgment Form - Town Of Centerville, Tennessee

Hippa Training Acknowledgment Form - Town Of Centerville, Tennessee - 2003

HIPPA TRAINING ACKNOWLEDGMENT FORM

Town of Centerville

As an employee, I hereby acknowledge that I have received and do now possess a complete and

current copy of the Town of Centerville’s Health Insurance Portability and Accountability Act

(HIPAA) Policy passed by resolution on ___________, 2003. I also acknowledge that I

received and participated in training on this policy on ____________, 2003.

I agree without reservation to follow and abide by the policies, procedures, rules and regulations

contained therein.

Furthermore, I understand that the Town reserves the right to change any of such rules,

regulations, policies, practices, and procedures in whole or in part at any time, with or without

notice to employees.

Name of Employee: _____________________________________________________________

Department Name: ______________________________________________________________

Social Security Number: _________________________________________________________

Signature of Employee ___________________________________

Date______________

Signature of Witness _____________________________________

Date______________

Hippa Training Acknowledgment Form - Town Of Centerville, Tennessee - 2003