Form Hipaa-F-2 Notice Of Privacy Practices Acknowledgment Form - Massachusetts Department Of Mental Health
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1Commonwealth 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.
q
Face to face meeting
q
Mailing
______________ by
Notice of Privacy Practices given to the individual on
q
Email
date
q
Other_____________________
____
Reason Individual or Personal Representative did not sign this form:
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
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.
Face to face presentation(s)__________________________________________________________
q
Telephone contact(s)________________________________________________________________
q
Mailing(s) ________________________________________________________________________
q
Email____________________________________________________________________________
q
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.
DMH Notice of Privacy Practices Acknowledgment Form
HIPAA-F-2 (4/14/03)
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