Health Insurance Portability and Accountability Act (HIPAA)
Notice of Privacy Practices Aknowledegment of Receipt of Notice of Privacy Practices
Participant's Name
*
Support Coordinator's email
*
example@example.com
Participant's Initials
*
Participants Address
*
Participant or Authorized Representative's Signature
*
Date
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Printed Name of Participant or Personal Representative
*
Support Coordinator's Signature
*
Support Coordinator's typed name
*
Date
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Region Number
*
Office Phone Number
*
Program Director's Name
*
Program Director's Email
*
example@example.com
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