ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES. This is to confirm that I have received a copy of this office’s Notice of Privacy Practices. I understand that I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to conduct, plan and direct my treatment, obtain payment from third party payors and conduct normal healthcare operations such as quality assessments and accreditation. Initials
ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES. I have received a copy of Allendale Dental’s NOTICE OF PRIVACY PRACTICES, and fully understand the “Payment Policy”, outlined above, accepting responsibility for all charges, deductibles, co-pays and uncovered items, not paid by my insurance. Please print patient name Relationship to patient X
ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES. I acknowledge that a copy of the HIPAA Notice of Privacy Practices had been made available and that I have read (or had the opportunity to read if I so chose) and understand the notice.
ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES. I acknowledge that I was provided a copy of the HIPAA Notice of Privacy Practices and that I have read (or had the opportunity to read if I so chose) and understand the Notice. The ACADEMY FOOT & ANKLE SPECIALISTS HIPAA rights are also posted in lobby and at xxx.xxxxxxxxxxxxxxx.xxx.
ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES. I acknowledge that I have received a copy of the Xxxxx Xxxxxxx Notice of Privacy Practices. Patient Name: Birth Date: _ (first) (m. initial) (last) Address: Phone #: (street address) Medical Record #: (city) (state) (zip code) (if known) Signature of Patient Only: Date: / /
ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES. We are legally required to provide you with a copy of our NOTICE OF PRIVACY PRACTICES the first time you receive care at UC Health. If you are here for emergency medical treatment, you will be given a copy as soon as possible. Patient or Patient’s Legal Representative: Check appropriate box and sign. ☐ ☐ ☐ I have reviewed a copy of the Notice of Privacy Practices. I have previously reviewed a copy of the Notice of Privacy Practices. I do not want a copy of the Notice of Privacy Practices. PATIENT/LEGAL REPRESENTATIVE RELATIONSHIP TO THE PATIENT Printed Name: Date: If your provider is located on the University of Cincinnati Medical Center Campus, Xxxxxx Xxxxx Center for Post-Acute Care Campus, West Xxxxxxx Hospital Campus, return the completed acknowledgement form to UC Health through any one (1) of the following methods. For questions, call 000-000-0000. ● Email: xxx-xxxxxxxx@xxxxxxxx.xxx ● Fax: 000-000-0000 ● Mail: West Xxxxxxx Hospital, Medical Records, 7700 Xxxxxxxxxx Xxxxx, Xxxxx X, Xxxx Xxxxxxx, OH 45069 ● In person: At your doctor’s office or at the Health Information Management Department address above on weekdays between 8 a.m. and 4:30 p.m. Picture identification is required. Please contact your provider's office if you have any questions. Disclaimer for electronic transmission By submitting this form, I understand and acknowledge, that if I decide to complete these forms and send them back to UC Health via this email exchange, UC Health cannot control and is not responsible for any compromised transmission of the email from your email server, or any compromise of your information that occurs with your email server storage. If you prefer to communicate via encrypted email, please let us know that before sending the forms back, and we will send you an encrypted email which will also be encrypted when you respond with the forms. If you would rather fax or mail the forms, please use the fax number or mailing address listed above. Click Here to Email Form Below this line is for UC HEALTH staff use only if the patient or patient’s legal representative has not acknowledged above. Employee: Check appropriate box and sign. ☐ Patient or Patient’s Legal Representative refused to sign Acknowledgement. Explain: ☐ Patient or Patient’s Legal Representative is unable to sign Acknowledgement. Explain: ☐ Patient or Patient’s Legal Representative has previously acknowledged receipt of Notice of Privacy Practices. Reset Form
ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES. Comprehensive Cancer Centers of Nevada is committed to protecting your privacy and ensuring that your health information is used and disclosed appropriately. This Notice of Privacy Practices identifies all potential uses and disclosures of your health information by our practice and outlines your rights with regard to your health information. Please sign the form below to acknowledge that you have received our Notice of Privacy Practices. I acknowledge that I have received a copy of the Notice of Privacy Practices of Comprehensive Cancer Centers of Nevada. Date: Name: Signature: Name of Personal Representative (if appropriate): Signature of Personal Representative (if appropriate): Comprehensive Cancer Centers of Nevada Use Only Date acknowledgment received: ) - OR- Reason acknowledgment was not obtained: Meaningful Use Update Name: Date of Birth: Race/Ethnicity: Preferred Language: Preferred Method of Contact Email: Cell: Home: Other: Marital Status Married Single Widowed Divorced Life Partner User Electronic Mail Authorization Form Patient Portal: My Care Plus My Care Plus, the Patient Portal (the “Portal”) offers convenient and secure access to your personal health record. As the patient, you are in control of your Portal record: we will not activate your personal account unless you authorize us to do so. Because personal identifying information is available via the Portal, it is very important that you keep your password private. Do not share your password with anyone or write it in a place easily accessible to others. If you choose not to execute this User Electronic Mail Authorization Form, you will not be able to access the Portal. If you choose to submit this form, you understand you are consenting for us to email you a unique link that you will use to create a password in order to access the Portal. Please look for an email from My Care Plus promptly after submitting this form. For your protection, the link is designed to expire quickly if not used. If you should change email addresses, please contact your physician’s office in order to provide your new email contact information so that you will continue to receive updates and other pertinent information. Please choose an email address that will not be subject to access by anyone you do not trust. If you wish to discontinue utilizing the Portal, please contact your physician’s office.
ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES. By signing this form, I agree to the terms and acknowledge that I have been provided with a copy of the Informed Consent and Notice of Privacy Practices document. This document provides information about agreements with my therapist regarding participation in therapy and how my protected health information may be used and disclosed. I have read it in full and understand these documents are subject to change. If I have any questions about my Notice of Privacy Practices, or wish to receive a copy of any revisions of the Informed Consent and Notice of Privacy Practices, I acknowledge that I may submit my request to Glendale-Arcadia-Counseling at 000 X. Xxxxx Xxxx., Xxx. 000 Xxxxxxxx, XX 00000, (000)000-0000 Therapist Qualifications Xxxxx Xxxxxxx, LCSW (LCS14276) is licensed to diagnose and treat mental health problems. Xxxxx Xxxxxxx, M. A. AMFT (12071) provides mental health treatment under the supervision of Xxxxx Xxxxxxx, LCSW (LCS14276).
ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES. You May Refuse to Sign This Acknowledgement* I, , have received a copy of this office's Notice of Privacy Practices. Signature Print Name Date ************************************************************************************************************ ****************************** FOR OFFICE USE ONLY We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because: ( ) Individual refused to sign ( ) Communications barriers prohibited obtaining the acknowledgement
