Suburban Geriatrics Acknowledgement Form Of Receipt Of Notice Of Privacy Practices printable pdf download

Suburban Geriatrics Acknowledgement Form Of Receipt Of Notice Of Privacy Practices

SUBURBAN GERIATRICS

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

Notice to Patient:

We are required to provide you with a copy of our Notice of Privacy Practices, which states how

we may use and/or disclose your health information. Please sign this form to acknowledge

receipt of the Notice. You may refuse to sign this acknowledgement, if you wish.

I acknowledge that I have received a copy of this office’s Notice of Privacy practices

Please print your name here

Signature

Date

FOR OFFICE USE ONLY

We have made every effort to obtain written

acknowledgement or receipt of our Notice of

Privacy from this patient, but it could not be obtained because:

 The patient refused to sign

 Due to an emergency situation it was not possible to obtain acknowledgement

 We weren’t able to communicate with the patient

Other (Please provide specific details)

___________________________________________________________________________

___________________________________________________

__________________

Employee signature

Date

HIPAA A

cknowledgement of receipt of the Notice of Privacy Practices

This form does not constitute legal advice and covers only federal, not state law.

Suburban Geriatrics Acknowledgement Form Of Receipt Of Notice Of Privacy Practices