Privacy Acknowledgement

Acknowledgement of Notice of Privacy Practices

 

Client Name: ________________________________

Date of Birth: _______________

I have been given or offered a copy of New Haven Youth and Family Services’ current Notice of Privacy Practices (“Notice”), which describes how Protected Health Information (“PHI”) and student records is used and shared.  I understand that New Haven has the right to change this Notice at any time.  I may obtain a current copy by contacting New Haven’s Privacy Officer or by visiting the New Haven website at http://www.newhavenyfs.org/privacy/

My signature below acknowledges that I have been provided with or offered a copy of Privacy Practices:

 

For clients who are minors:

________________________________         ________________

Signature of Parent, Guardian, or Representative     Date

 

For clients who are non-minors:

________________________________         ________________

Signature of Youth                                                            Date

 

________________________________         _________________

Signature of NHYFS Representative                             Date


New Haven use: Complete this section if you are unable to obtain a signature:

  1. If the client or parent/legal guardian is unable or unwilling to sign this Acknowledgement, or the Acknowledgement is not signed for any other reason, state the reason:___________________________________________
  2. Describe the steps take to obtain the client’s or parent/legal guardian’s signature on the Acknowledgement: _________________________________________________

 

Completed by:

____________________________   ________________

Signature of New Haven Representative     Date

 

__________________________________

Printed Name of New Haven Representative