Privacy-Practices-Acknowledgement

Name of Practice*
SECTION A: The Patient.
Name*
Address*
Telephone*
Format: (000) 000-0000.
E mail*
example@example.com
Patient Number
Social Security Number
SECTION B: Acknowledgement of Receipt of Privacy Practices Notice.
I, name acknowledge that I have received a Notice of Privacy Practices from the above-named practice.
Signature*

Clear
Date*

MonthDayYear
Date
If a personal representative signs this authorization on behalf of the individual, complete the following:
Personal Representative's Name
Relationship to Individual
SECTION C: Good Faith Effort to Obtain Acknowledgement of Receipt.
Describe your good faith effort to obtain the individual's signature on this form:
Describe the reason why the individual would not sign this form:
SIGNATURE.
I attest that the above information is correct.
Signature*

Clear
Date*

MonthDayYear
Date
Print name*
Title
Include this acknowledgement of receipt in the individual's records.
ACKNOWLEDGEMENT OF RECEIPT OF PRIVACY PRACTICES NOTICE
Should be Empty: