Notice of Privacy Practices

Acknowledgment of Receipt of Notice of Privacy Practices (NPP)

By checking the box 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 hospitals and the facilities listed at the beginning of this notice, and how I may obtain access to and control this information.
Patient name:
Printed name of patient or personal representative
Today's date:
MM slash DD slash YYYY
Description of personal representative's authority:
I was not able to obtain the patient's acknowledgement of receipt of the NPP upon registration because:
- The patient refused to sign despite good faith efforts
- The patient was unaccompanied and not alert and oriented
- The patient was unaccompanied and needed emergency care
Other (please explain):
Employee title:
Employee printed name:
Today's date:
MM slash DD slash YYYY
Consent
Acknowledgement subsequently obtained (see above).
I have also read the HIPPA Notice of Privacy Practices.
Your email address:*
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Phone
This field is for validation purposes and should be left unchanged.

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