Submit
Cancel

Acknowledgement of Notice of Privacy Practices (HIPAA) (Web)

Community & Family Resources
Phone 515-576-7261
Fax 515-955-7628
 Client Information
  First Name:  * Last Name:  *  
           
  Date of Birth:  * Birth Sex: 
* 
         
  Address: City:  
  State: Zip Code :  
  Phone No:  
Date
Medicaid #
Medicare #
* Was written Notice of Privacy Practices provided?
Yes  
No  
* Was Notice given in another way?
Yes  
No  
If written Notice was not provided, method of Notice:
Verbal  
Fax  
Email  
Website  
Other  
* Client Signature
Signer Type:
Name:
 
Sign with Touch
Comments:
Form Updates
Name Date Action
    Form Started
  1. Click the "Submit" button to save the data entered on this form.
  2. Click the "Cancel" button to exit without saving recent updates on this form.