DMH Notice of Privacy Practices Acknowledgment Form.pdf

DMH Notice of Privacy Practices Acknowledgment Form

HIPAA-F-2 (4/14/03)

Commonwealth of Massachusetts Department of Mental Health

Notice of Privacy Practices Acknowledgment Form

Name: DMH ID#

Facility/Site/Program:

I have received a copy of the DMH Notice of Privacy Practices (Version_______ Effective Date______)

Signature: Date: .

Individual or Personal Representative with legal authority to make healthcare decisions

If signed by a Personal Representative:

Print Name__________________________________________ Role______________________ (Parent, guardian, etc.)

Witness:_________________________________________ Date:___________________ If the individual has a personal representative with legal authority to make health care decisions on the individual's behalf, the notice must be given to and acknowledgment obtained form the personal representative. If the individual or Personal Representative did not sign above, staff must document when and how the notice was given to the individual, why the acknowledgment could not be obtained, and the efforts that were made to obtain it.

Notice of Privacy Practices given to the individual on______________ by date

Reason Individual or Personal Representative did not sign this form:

q Individual or Personal Representative chose not to sign q Individual or Personal Representative did not respond after more than one attempt q Email receipt verification q Other ____________________________________________________________________________

Good Faith Efforts: The following good faith efforts were made to obtain the individual or Personal Representative's, if applicable, signature. Please document with detail (e.g., date(s), time(s), individuals spoken to and outcome of attempts) the efforts that were made to obtain the signature. More than one attempt must have been made.

q Face to face presentation(s)__________________________________________________________ q Telephone contact(s)________________________________________________________________ q Mailing(s) ________________________________________________________________________ q Email____________________________________________________________________________ q Other_____________________________________________________________________________

Staff Signature:_______________________________________ Title____________________________

Print Name: _________________________________________ Date_____________________

This form must be retained for a period of at least six years in the appropriate record in accordance with the DMH Privacy Handbook.

q Face to face meeting q Mailing q Email q Other_____________________