Print and Sign
Notice of Privacy Practices
Receipt and Acknowledgment of Notice
Patient/Client Name: ________________________________
Date Of Birth:_____________________________________
SS#:____________________________________________
I hereby acknowledge that I have received and have been given an opportunity read a copy of Roland Gabbert's Notice of Privacy Practices.
I understand that if I have any questions regarding the Notice or my privacy rights, I can contact Mr. Gabbert.
_________________________________________________
Signature of Patient/Client; Date
_________________________________________________
Signature of Parent, Guardian or Personal Representative; Date
* If you are signing as a personal representative of an individual,
please describe your legal authority to act for this individual (power of attorney, healthcare surrogate, etc.).
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Patient/Client Refuses to Acknowledge Receipt:
_________________________________________________
(Signature of Staff Member; Date)
