Common use of Acknowledgement of Receipt Clause in Contracts

Acknowledgement of Receipt. Notice of Privacy Practices By signing this form, you acknowledge that you have received the Notice of Privacy Practices of The Cradle and its practicing providers of service. This Notice of Privacy Practices provides information about how we may use and disclose your protected health information. We encourage you to read it in full. The Notice of Privacy Practices is subject to change. You may obtain a copy of the current notice by: • viewing our website at xxx.xxxxxx.xxx, • visiting reception desk or waiting areas • contacting our Privacy Officer at (000) 000-0000 or The Cradle, 0000 Xxxxx Xxx., Xxxxxxxx, XX, 00000 I acknowledge that I have received the Notice of Privacy Practices. Signature Printed Name Date (Client, parent, conservator, guardian) Signature Printed Name Date (Client, parent, conservator, guardian) If no signature is obtained above, describe the good faith efforts made to obtain the individual's acknowledgement, and the reasons why the acknowledgement was not obtained:

Acknowledgement of Receipt. Notice of Privacy Practices By signing this form, you acknowledge that you have received the Notice of Privacy Practices of The Cradle and its practicing providers of service. This Notice of Privacy Practices provides information about how we may use and disclose your protected health information. We encourage you to read it in full. The Notice of Privacy Practices is subject to change. You may obtain a copy of the current notice by: •  viewing our website at xxx.xxxxxx.xxx, •  visiting reception desk or waiting areas •  contacting our Privacy Officer at (000) 000-0000 or The Cradle, 0000 Xxxxx Xxx., Xxxxxxxx, XX, 00000 I acknowledge that I have received the Notice of Privacy Practices. Signature Printed Name Date (Client, parent, conservator, guardian) Signature Printed Name Date (Client, parent, conservator, guardian) If no signature is obtained above, describe the good faith efforts made to obtain the individual's acknowledgement, and the reasons why the acknowledgement was not obtained: