Acknowledgment of Receipt of Notice

Patient name:        ________________________________  Medical Record Number        ____________

I have received a copy of Puget Sound Home Health, LLC’s Notice of Privacy Practices.

Signature:              ______________________________________________     Date        ____________

If personal representative:  Name:     ________________________________________________

Relationship to Patient:       ______________________________________________________

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Reason signature not obtained:

                [  ]           Patient too sick to sign at this time.

                [  ]           Patient would not sign.

                [  ]           Other:     ____________________________________________________________

Name of Puget Sound Home Health, LLC employee attempting unsuccessfully to obtain signature:

______________________________________________________________________________

Date:       _____________________________________

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Notes:                    (1) Rather than develop a separate Acknowledgment form, an agency may modify its “Consent to Treat” form by adding above the signature line:

                                “I hereby also acknowledge that I have received a copy of Puget Sound Home Health, LLC’s Notice of Privacy Practices.”

                                (2) Except in an emergency treatment situation the agency must make a good faith effort to obtain the signature of the patient or personal representative acknowledging receipt of the Notice.

                                (3) If the signature cannot be obtained, the agency must document its efforts to obtain the signature and the reason why the signature was not obtained.