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Department of Health and Human Services
Behavioral Health

HIPAA Forms - Acknowledgement of Receipt of Notice of Privacy Practices

______________________________________________
Consumer's Name

We are required by Federal Law to give you this notice and to prove that you received it.

You may use your mark or a stamp if you are unable to sign this form.

I, ______________________________________, have been given a copy of the BDS
 Printed or Typed Name of Person Receiving Notice

Privacy Notice.
 

___________________________________________________________________
Signature of Patient/legal representative                                             Date

I gave ____________________________________ a copy of this Privacy Notice on
                  Patient/legal representative

_______________________ but he/she declined to sign for it.
                     Date
                            
        

___________________________________________________________________
Employee /Witness Signature                                                                            Date

  

  

  

Revised 7.21.03

 

 

 

State of Maine Hospitals/Facilities

• Dorothea Dix Psychiatric Center
• Riverview Psychiatric Center

Administration

• Central Administration
• Region I
• Region II
• Region III
• Notice of Privacy Practices
• Personnel Complaints Policy

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