IHS-982 Acknowledgement of receipt of the Notice of Privacy Prac

Acknowledgement of Receipt of IHS Notice of Privacy Practices

By signing this form, you acknowledge receipt of the Indian Health Service (IHS) Notice of Privacy Practices. Our Notice of Privacy Practices provides information about how we may use and disclose your medical information. We encourage you to read it in full.

Our Notice of Privacy Practices is subject to change. If we change our notice, you may obtain a copy of the revised notice by logging onto https://www.ihs.gov/sites/hipaa/themes/responsive2017/display_objects/documents/NoticePrivacyPracticePamphlet.pdf or by contacting the IHS Privacy Officer at (240) 479-8521.

If you have any questions about our Notice of Privacy Practices, please contact the IHS Privacy Officer at (240) 479-8521.

Name of Patient

Signature of Patient Date

If patient is unable to sign:

Name of Legal Representative and state relationship to patient

Signature of Patient Representative Date

Signature and Title of CSU Staff Date

Staff Only: For Patients Unable to Acknowledge Receipt

I hereby certify that the patient was unable to acknowledge receipt of the IHS Notice of Practices because:

Signature of IHS Staff Date

IHS Staff Use Only:

Health Record Number: D.O.B. _____________

OMB STATEMENT

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0917-0030. The time required to complete this information collection is estimated to average less than 10 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, to review and complete the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: Indian Health Service, OMS/DRPC, 5600 Fishers Lane, Rockville, MD 20857, Attention: Information Collections Clearance Officer.