I agree that I have received a copy of the UMMC Notice of Privacy Practices.
Print Patient?s Name ___________________________ Date ___________
Signature of patient or representative _______________________________
Description of personal representative?s authority ______________________
UMMC Use Only
The following should be completed only if the patient cannot sign or refuses to sign the acknowledgement
We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but UMMC was unable to obtain acknowledgement because:
Employee Signature ________________________________ I.D. Number ________