[
    {
        "page": 1,
        "items": [
            {
                "page": 1,
                "type": "TITLE",
                "location": {
                    "l": 213.12,
                    "t": 718.8,
                    "r": 454.08,
                    "b": 678.24
                },
                "text": "Acknowledgement of Receipt of Notice of Privacy Practices",
                "reading_order": 0,
                "level": 1
            },
            {
                "page": 1,
                "type": "TEXT",
                "location": {
                    "l": 164.4,
                    "t": 663.36,
                    "r": 504.72,
                    "b": 648.96
                },
                "text": "Name: ___",
                "reading_order": 1
            },
            {
                "page": 1,
                "type": "TEXT",
                "location": {
                    "l": 69.6,
                    "t": 634.8,
                    "r": 506.4,
                    "b": 618.48
                },
                "text": "Address: ___",
                "reading_order": 2
            },
            {
                "page": 1,
                "type": "TEXT",
                "location": {
                    "l": 69.36,
                    "t": 604.56,
                    "r": 494.16,
                    "b": 588.72
                },
                "text": "Facility Name: Kentucky State University, Betty White Student Health Services",
                "reading_order": 3
            },
            {
                "page": 1,
                "type": "TEXT",
                "location": {
                    "l": 68.64,
                    "t": 574.56,
                    "r": 540.48,
                    "b": 512.88
                },
                "text": "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.",
                "reading_order": 4
            },
            {
                "page": 1,
                "type": "TITLE",
                "location": {
                    "l": 68.88,
                    "t": 499.68,
                    "r": 534.48,
                    "b": 469.68
                },
                "text": "My signature below acknowledges that I have been offered a copy or provided with a copy of the NPP:",
                "reading_order": 5,
                "level": 2
            },
            {
                "page": 1,
                "type": "TEXT",
                "location": {
                    "l": 69.36,
                    "t": 466.32,
                    "r": 509.04,
                    "b": 454.56
                },
                "text": "___",
                "reading_order": 6
            },
            {
                "page": 1,
                "type": "TEXT",
                "location": {
                    "l": 69.6,
                    "t": 453.6,
                    "r": 495.12,
                    "b": 439.92
                },
                "text": "Signature of Patient Date",
                "reading_order": 7
            },
            {
                "page": 1,
                "type": "TEXT",
                "location": {
                    "l": 71.04,
                    "t": 420.72,
                    "r": 509.28,
                    "b": 397.68
                },
                "text": "Print Name",
                "reading_order": 8
            },
            {
                "page": 1,
                "type": "TEXT",
                "location": {
                    "l": 69.84,
                    "t": 394.8,
                    "r": 525.36,
                    "b": 363.36
                },
                "text": "Personal Representative’s Title (e.g., Guardian, Executor of Estate, Health Care Power of Attorney)",
                "reading_order": 9
            },
            {
                "page": 1,
                "type": "TEXT",
                "location": {
                    "l": 69.6,
                    "t": 350.16,
                    "r": 506.88,
                    "b": 320.64
                },
                "text": "For Department Use Only: Complete this section if you are unable to obtain a signature.",
                "reading_order": 10
            },
            {
                "page": 1,
                "type": "TEXT",
                "location": {
                    "l": 68.64,
                    "t": 317.04,
                    "r": 535.44,
                    "b": 244.32
                },
                "text": "If the patient or personal representative is unable or unwilling to sign this\nAcknowledgement, or the Acknowledgement is not signed for any other reason, state the\nreason:",
                "reading_order": 11
            },
            {
                "page": 1,
                "type": "TEXT",
                "location": {
                    "l": 68.88,
                    "t": 229.92,
                    "r": 543.36,
                    "b": 134.64
                },
                "text": "Describe the steps taken to obtain the patient's (or personal representative's) signature on the Acknowledgement:",
                "reading_order": 12
            }
        ]
    }
]