Acknowledgment Of Receipt Of Notice Of Privacy Practices

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GRANTS PASS CHIROPRACTIC CLINIC
Acknowledgment of Receipt of Notice of Privacy Practices
Patient Name: ________________________________________
Patient ID #: _______________________
I hereby acknowledge that I have viewed a copy of GRANTS PASS CHIROPRACTIC CLINIC’s Notice of
Privacy Practices. I understand that I have the right to refuse to sign this acknowledgment if I so choose.
____________________________________________________
__________________________________
Signature of Patient or Legal Representative
Date
Relationship to Patient (if applicable)
____________________________________________________
Parent or guardian of unemancipated minor
Printed Name of Patient’s Representative (if applicable)
Court appointed guardian
Executor or administrator of decedent's estate
Power of Attorney
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FOR OFFICE USE ONLY
We attempted to obtain written acknowledgment of receipt of our Notice of Privacy Practices on the following date,
_____________________________ but acknowledgment could not be obtained because:
Patient/representative refused to sign
Emergency situation prevented us from obtaining acknowledgment at this time
(will attempt again at a later date)
Communication barriers prohibited obtaining acknowledgment (Explain)
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Other (Specify)
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

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