HIPAA - Acknowledgement of Receipt of Notice of Privacy Practice

LCOHPA- ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

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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.

Patient or Patient's Legal Representative has:

Patient received a Copy of the Notice of Privacy Practices.

Patient has previously received a Copy of the Notice of Privacy Practices

Patient does not want a Copy of the Notice of Privacy Practices

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Patient Name*

First Last

Patient DOB*

Relationship to patient

Patient Signature*

Date*

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