ACKHNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTIVES (NOPP)

By signing below, I ackhnowledge that I have been provided a copy of this Notice of Privacy Practices and have therefore been advised of how health information about me may be used and disclosed by the hospitals and the facilites listed at the beginning of this notice, and how I may obtain access to and control this information.

Signature of Patient or Personal Representative

I was not able to obtain the patient's acknowledgement of receipt of the NOPP upon registration because:

The patient refused to sign despite good faith efforts The patient was unaccompanied and not alert and oriented The patient was unaccompanied and needed emergency care Other

ACKHNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTIVES (NOPP)

Signature of Patient or Personal Representative

I was not able to obtain the patient's acknowledgement of receipt of the NOPP upon registration because:

Signature of Patient or Personal Representative

Acknowledgement subsequently obtained