Acknowledgement of Receipt of Notice of Privacy Practices

Please correct the errors described below.

I acknowledge that I have received a copy of Provider's Notice of Privacy Practices with the effective date of March 13, 2015.

Documentation of Good Faith Efforts
To obtain patient’s acknowledgment that they received provider’s Notice of Privacy Practices

(For use when acknowledgment cannot be obtained from the patient.)

and was provided with a copy of Covered Entity's Notice of Privacy Practices. A good faith effort was made to obtain from the patient a written acknowledgment of his/her receipt of the Notice. However, such acknowledgement was not obtained because:

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