SCCS Acknowledgement of Receipt of Notice of Privacy Practices

Acknowledgement of Receipt of Notice of Privacy Practices

Communicare, Inc. - South Central Crisis Services
Name of Individual*

First NameLast Name
· I have received South Central Crisis Services’ Notice of Privacy Practices currently in effect.

· I understand staff are available to review and discuss my rights, as described in the Notice of Privacy Practices, if requested
Signature of Individual or Personal Representative

Clear
Date

MonthDayYear
Date
If signed by the individual’s representative, describe the legal authority of the representative to act on behalf of the individual:
Name of Witness

First NameLast Name
Unable to obtain written consent and acknowledgment because:

Individual RefusedEmergency Treatment SituationIndividual not able to sign due to incompetence or other medical reasonOther
Signature of Staff:*

Clear
Agency receiving form:*
Should be Empty: