Consent And Acknowledgment (Page 4 of 4) in pdf

Consent And Acknowledgment Page 4

CONSENT and ACKNOWLEDGMENT

Receipt of Notice of Privacy Practices

[For use by Kane County Health Department clients upon first visit, or by existing clients required

to sign for acknowledgment of receipt of the Kane County Notice of Privacy Practices.]

I, ___________________________________ do hereby consent to allow the health department

(print name of client)

and its designated employees and contractors to_______________________________________

_____________________________________________________________________________________

(example: perform a medical evaluation and treat conditions found therein). I understand the nature and

consequences of any procedures to be performed will be explained to me.

I understand that the health department is already authorized to use the information gained during

treatment to bill me, my insurance company, or any other potential sources of reimbursement, such as

government programs in which I am enrolled or qualify for services.

I also hereby acknowledge that I received a copy of the “Notice of Privacy Practices” from the health

department dated April 14, 2003.

___________________________________

Signed

____________________

Date

Check if any of the following apply:

Parent or Guardian of minor

Health Care Surrogate

Power of Attorney for Health Care

Mental Health Treatment Preference

Declaration Agent

Guardian with power to make health care decisions

-------------------------------------------------------------------------------------------------------------------------------

FOR STAFF USE ONLY:

Patient Name: ____________________________________________________

Client Number: ___________________________________________________

Participant/Legal Guardian Name: ____________________________________

I attempted to obtain an Acknowledgment of the Receipt of the Notice of Privacy Practices on behalf of

the HD. The HD was unable to obtain the Acknowledgment because:

1 Client refuses to sign 1Other (specify): _____________________________________________

____________________(Staff member’s initials)

_________________________(Date)

(Staff: Place Acknowledgment in patient’s medical record.)

Notice of Privacy Practices

Kane County Health Department, Kane County, IL

Page 4

4/03

Consent And Acknowledgment Page 4