ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

By signing below, I acknowledge that I have been provided a copy of this Notice of Privacy Practices and have therefore been advised of how health information about me may be used and disclosed by the hospital and the facilities listed at the beginning of this Notice, and how I may obtain access to and control this information. I also acknowledge and understand that I may separate written explanations of special privacy protections that apply to HIV-related information and mental health information.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

(For internal use B where signature above cannot be obtained)

Except in emergency treatment circumstances, the Health Insurance Portability and Accountability Act of 1996 (AHIPAA) requires that we make a good faith effort to obtain written acknowledgment of the patients receipt of the Notice of Privacy Practices on the first date after April 14, 2003 we provide treatment, products or services contact with the patient). We must make a good faith effort to obtain written acknowledgment when reasonably practicable following an emergency treatment situation. If such acknowledgement cannot be obtained, we must document our good faith efforts to obtain the acknowledgment and why it was not obtained.

Describe good faith efforts to obtain written acknowledgment (include your name and the date):

THE ORIGINAL OF THIS FORM MUST BE PLACED IN THE MEDICAL RECORD

Purpose: This form is used to obtain acknowledgement of receipt of our Notice of Privacy Practices or to document our good faith effort to obtain that acknowledgement