Acknowledgement Of Receipt Notice Of Privacy Practices printable pdf download

Acknowledgement Of Receipt Notice Of Privacy Practices

ACKNOWLEDGEMENT OF RECEIPT

NOTICE OF PRIVACY PRACTICES

We are legally required to give you this Notice and to get a signed statement that you received it. By

signing this form, you are saying that you have received Coastal Carolina Health Care, P.A.’s Notice of

Privacy Practices.

Coastal Carolina Health Care, P.A.’s Notice of Privacy Practices tells you how we can use and disclose

your health information. It also describes certain rights you have about your health information kept by

us. Please review the Notice of Privacy Practices carefully.

The undersigned hereby acknowledges receipt of Notice of Privacy Practices for Coastal Carolina

Health Care, P.A and each of its locations and components.

______________________________

___________________________

Patient’s Printed Name

Medical Record Number

______________________________

___________________________

Patient Signature

Date

______________________________

____________________________

Parent/Guardian Signature

Relationship to Patient

If the patient did not sign an acknowledgement of receipt of the Notice of Privacy Practices, complete

the following:

List efforts taken to get patient’s acknowledgement and reasons acknowledgement was not signed:

________________________________________________________________________________________

_____________________________________

_______________________

Signature of Staff Member

Location

_________________________________________

_______________________

Printed Name of Staff Member

Date

Acknowledgement Of Receipt Notice Of Privacy Practices