ACKNOWLEDGEMENT OF RECEIPT OF PRIVACY NOTICE

By signing this form, you acknowledge that Grogan & Howard, PSC has given you a copy of its Privacy Notice, which explains how your health information will be handled in various situations. We must try to have you sign this form on your first date of service after April 1, 2003. This includes the situation where your first date of service occurred electronically.

If your first date of service with us was due to an emergency, we must try to give you this notice and get your signature acknowledging receipt of this notice as soon as we can after the emergency.

Check all that are true:

 I have received Grogan & Howard, PSC’s Privacy Notice.

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Patient’s Signature Date

To be completed by Grogan & Howard, PSC staff if Acknowledgement Form is not signed:

Patient Name: ____________________________________________

DOS: ___________________________________________________

1. Does patient have a copy of the Privacy Notice?  Yes  No

2. Please explain why the patient was unable to sign an acknowledgement form and Grogan & Howard, PSC’s efforts to obtain the patient’s signature:

_____________________________________________________________________

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_____________________________________________________________________

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Signature: _________________________________________ Date: ______________________