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Privacy Policy

Acknowledgement of Reading Notice of Privacy Practices

This template can be used to create a document to confirm that a service's client has read and accepted the privacy practices of your busines as stated within a previously provided policy.

Acknowledgement of Reading Notice of Privacy Practices

Prior to signing this document, I have received the Notice of Privacy Practices from [Company]. I understand that the Notice describes the types of uses and disclosures of my protected health information that will occur as part of getting services or treatment, or for the payment of my bills and the performance of health care operation of [Company]. The Notice also describes my rights and the service providers' duties with respect to my protected health information. [Company] provides the Notice of Privacy Practices at all [Company] managed facilities.

I understand that [Company] reserves the right to change its privacy practices and that I may obtain a revised Notice of Privacy Practices by calling the agency's main office and requesting that a copy be mailed to me or by asking for a copy at my next appointment.I have been informed that any questions I have about the notice should be directed to the Privacy Officer at [Company], [Street Address], [City], [State], [Zip Code], [Phone Number].

Signature of Person in Service



(Please check only one)

____ Mental Health

____ Adult Services

____ Parenting

____ Early Intervention

____ Foster Adoptive Parenting

____ Personal Care

NOTE: If person requesting service has been discharged and is reapplying, a new Acknowledgement of Reading Notice of Privacy Practices needs to be signed.

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