Privacy Notice Form – California Coast Physicians

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Acknowledgement of Receipt of Privacy Practice Notice

Please Print Name(Required)

First

Last

Date of Birth(Required)

MM slash DD slash YYYY
Date(Required)

MM slash DD slash YYYY

If a personal representative signs this authorization on behalf of the individual, complete the following:

Personal representative's name(Required)

First

Last

Relationship to individual(Required) Representative's telephone(Required)Date(Required)

MM slash DD slash YYYY
Signature

Good Faith Effort to Obtain Acknowledgement of Receipt

We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because:

Individual refused to sign

Communications barriers prohibited obtaining the acknowledgement

An emergency situation prevented us from obtaining

Other

The updated Notice of Privacy Practices has been made available to me.

Date

MM slash DD slash YYYY
Signature