Marion County Health Department

NOTICE OF PRIVACY PRACTICES
Acknowledgement of Receipt

                                                    


PLEASE REVIEW THIS ACKNOWLEDGEMENT CAREFULLY AND THEN SIGN AND DATE BELOW.


The Notice of Privacy Practices tells you how the Marion County Health Department may collect, use or disclose health information about you and tells you about your privacy rights. The Health Department is required to offer you a Notice of Privacy Practices by federal law. 

I, ________________________________________________, (client’s printed name)

have been offered a copy of the Marion County Health Department’s Notice of Privacy Practices and have had a chance to ask questions about how my health information will be collected, used and disclosed and how to access my privacy rights. 


_________________________________________    ___________________
Client’s Signature                                                                     Date

_________________________________________            ___________________
Legal or Personal Representative of Client (if applicable)     Relationship


This document is available in other languages and alternate formats that meet the
guidelines for the Americans with Disabilities Act (ADA).
Contact your Service Provider, or call the general number for the Health Department at: Phone# 503-588-5357, or Fax# 503-364-6552. 

Health Department Staff: Please have this document completed and signed by the individual receiving the Notice of Privacy Practices. 

Effective Date: June 1, 2013