Virginia Oculofacial Surgeons

ACKNOWLEDGMENT: RECEIPT OF NOTICE OF PRIVACY PRACTICES

I have received a copy of Virginia Oculofacial Surgeons Notice of Privacy Practices effective April 14, 2003.

Full Name:*

Date:*

I am a parent or legal guardian of (put patient name in the below filed). I have received a copy of Virginia Oculofacial Surgeons Notice of Privacy Practices effective April 14, 2003.*

Name:*

Relationship to Patient:*

Parent

Legal Guardian

Date:*

If the individual or parent/legal guardian did not sign above, staff must document when and how the Notice was given to the individual, why the acknowledgment could not be obtained, and the efforts that were made to obtain it.

Notice of Privacy Practices effective April 14, 2003 given to individual on (date)*

In Person

Mailing

Other

Reason individual or parent/legal guardian did not sign this form:

Did not want to

Did not respond after more than one attempt

Other

The following good faith efforts were made to obtain the individual or parent/legal guardian’s signature. Please document with dates, times, individuals spoken to, and outcome, as applicable, the efforts that were made to obtain the signature. More than one attempt must be made.

In person conversation*

Telephone contact*

Mailing*

Email*

Other*

Staff Name*

Title*

Date*

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