Acknowledgement of Receipt of Notice of Privacy Practices

RUTH HASKINS, MD, INC.

(916) 817-2649

 

 

 

I hereby acknowledge that I received a copy of this medical practice's Notice of Privacy Practices.  I further acknowledge that a copy of the current notice will be available in the reception area, available on the practice website (www.ruthhaskinsmd.com), and that a copy of any amended Notice of Privacy Practices will be made available upon request at each appointment.

 

         

Signed: ______________________________     Date: __________________________

Print Name:  __________________________     Telephone: _____________________

If not signed by the patient, please indicate relationship:

 

                      ¨    parent or guardian of minor patient

                      ¨    guardian or conservator of an incompetent patient

                     

 

Name and Address of Patient: _________________________________________

 

 

                                                                 __________________________________________

 

 

Signature not obtained: 

       ______        Patient unable to sign

 

       ______        Patient unwilling to sign

 

       ______        Notice mailed to patient, signature pending

 

 

________________________________________                                 _________________

Name of Practice Representative                                                               Date

 

 

 

 

 

 

Notice of Privacy Practices Acknowledgments Tracking Information

Name of Patient:  _______________________________________________________

Address:  ______________________________________________________________

_______________________________________________________________________

 

For Office Use Only:

Date received:

Processed by:

Practice Follow-up:  ٱ  Yes  ٱ  No

Date of Practice Follow-up:

 

Complete the following only if the Patient refuses to sign the Acknowledgment:

 

Efforts to obtain:

                      _____________________________________________________________

 

                             _____________________________________________________________

 

Reasons for refusal:

                      _____________________________________________________________

                             _____________________________________________________________