Adult Adopted Person Forms - The Cradle
Adult Adopted Person Forms - The Cradle
Adult Adopted Person Forms - The Cradle
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Notice of Privacy Practices<br />
Receipt and Acknowledgment of Notice<br />
Client Name:_____________________________________________<br />
DOB: ___________________________________________________<br />
SSN (Optional):___________________________________________<br />
I hereby acknowledge that I have received and have been given an opportunity to<br />
read a copy of <strong>The</strong> <strong>Cradle</strong>’s Notice of Privacy Practices. I understand that if I have<br />
any questions regarding the Notice or my privacy rights, I can contact Merrilee<br />
Hepler, Vice President, Human Resources & Administration and Risk<br />
Management Officer, located at <strong>The</strong> <strong>Cradle</strong>, 2049 Ridge Ave., Evanston, IL,<br />
60201, 847-733-3223.<br />
_________________________________________________________________<br />
Signature of Client<br />
Date<br />
_________________________________________________________________<br />
Signature of Parent, Guardian or <strong>Person</strong>al Representative Date<br />
__________________________________________________________________<br />
*<br />
If you are signing as a personal representative of an individual, please describe your<br />
legal authority to act for this individual (For example, power of attorney).<br />
Client Refuses to Acknowledge Receipt:<br />
_________________________________________________________________<br />
Signature of Staff Member<br />
Date<br />
Mac HD:Users:jsutherland:Desktop:downloads:HIPAA Receipt & Ackn#4233E4.doc
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