Privacy Notice Form

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Please Print Name(Required)

First Last

Date of Birth(Required)

Date(Required)

Personal representative's name(Required)

First Last

Relationship to individual(Required)

Representative's telephone(Required)

Date(Required)

Signature

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

Signature

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