Name of Patient: ___________________________________________
Patient Date of Birth: ________________________________________
Acknowl edge ment of Recei pt of Noti ce of Pri vacy Practi ces
A copy of our Noti ce of Pri vacy Poli ci es can be obt ai ned on our websi te at www.IMMUNOe.co m or
www.Hori zonPedi atri cs.com or upon request . I acknowl edge t hat I have been i nfor med of how t o obt ai n a
copy of the Noti ce of Pri vacy Poli cy.
_____________________________________
Si gnat ur e of Pati ent / Pati ent Repr esent ati ve
__________________________
Date
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Rel ati onshi p to Pati ent
Docu ment ati on of Good Faith Eff orts
To obt ai n pati ent ’s acknowl edge ment that they recei ved pr ovi der ’s
Noti ce of Pri vacy Practi ces
The pati ent present ed to the offi ce/hospi tal on _____________________ (dat e) and was pr ovi ded wit h a copy of
Cover ed Entity’s Noti ce of Pri vacy Practi ces. A good faith eff ort was made t o obt ai n fromt he pati ent a written
acknowl edge ment of hi s/her recei pt of the Noti ce. However , such acknowl edgement was not obt ai ned because:
Pati ent ref used to si gn
Pati ent was unabl e to si gn or i niti al because:
____________________________________________________________________________________________
The pati ent has a medi cal emer gency, and an atte mpt to obt ai n the acknowl edgement will be made at the next
avail abl e opport uni ty.
Ot her reason (descri be bel ow):
_____________________________________________________________________________________________
Si gnat ur e of Empl oyee Compl eti ng For m:
Dat e: ______________________________________________________
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