LCOH - ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES "*" indicates required fields 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 MRN: Patient Name:* First Last Patient DOB:* MM slash DD slash YYYY Relationship to patient:* Patient Signature:*Date* MM slash DD slash YYYY CAPTCHA