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 ________