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:
_____________________________________________________________
_____________________________________________________________