Acknowledgement of Receipt of Notice of Privacy Practices

Name: ___

Address: ___

Facility Name: Kentucky State University, Betty White Student Health Services

I acknowledge that I have received or been offered a copy of Kentucky State University’s (KSU) Notice of Privacy Practices (NPP) which describes how my Protected Health Information is used and shared. I understand that KSU has the right to change this NPP at any time. I may obtain a current copy by contacting KSU’s Student Health Services.

My signature below acknowledges that I have been offered a copy or provided with a copy of the NPP:

___

Signature of Patient Date

Print Name

Personal Representative’s Title (e.g., Guardian, Executor of Estate, Health Care Power of Attorney)

For Department Use Only: Complete this section if you are unable to obtain a signature.

If the patient or personal representative is unable or unwilling to sign this Acknowledgement, or the Acknowledgement is not signed for any other reason, state the reason:

Describe the steps taken to obtain the patient's (or personal representative's) signature on the Acknowledgement: