SCCS Acknowledgement of Receipt of Notice of Privacy Practices

Acknowledgement of Receipt of Notice of Privacy Practices

Communicare, Inc. - South Central Crisis Services
Name of Individual

First NameLast Name
· I have received South Central Crisis Services’ Notice of Privacy Practices currently in effect.

· I understand staff are available to review and discuss my rights, as described in the Notice of Privacy Practices, if requested
Signature of Individual or Personal Representative
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
If signed by the individual’s representative, describe the legal authority of the representative to act on behalf of the individual:
Name of Witness

First NameLast Name
Unable to obtain written consent and acknowledgment because:

Other
Signature of Staff:
Agency receiving form:
Should be Empty: