901-682-1516
ACKNOWLEDGEMENT
OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
Healthcare operations generally include those activities we perform to
improve our patient quality of care. We
have prepared a detailed NOTICE OF PRIVACY PRACTICES to help you better
understand our polices about our personal health
information.
The terms of the notice may change with time and we will always post
the current notice at our facility and have copies available for distribution.
I, __________________________________________, have received a copy of
_____________________________________________ Date: _____/_____/_____
Patient Signature
Office Use Only
We attempted to obtain written acknowledgement of receipt of our NOTICE
OF PRIVACY PRACTICES, but the acknowledgement could not be obtained due to:
____________________
Individual refused to sign
___________________
Communication barriers prohibited obtaining the acknowledgement
___________________
An emergency situation prevented us from obtaining
acknowledgement
YOU ARE ENTITLED TO A COPY OF
THIS CONSENT AFTER YOU SIGN IT