Get Privacy Notice Acknowledgment Form - University Of Iowa Hospitals ... - Uihealthcare

This guide provides clear instructions on how to complete the Privacy Notice Acknowledgment Form at the University of Iowa Hospitals. By following the steps outlined below, users can ensure they properly acknowledge receipt of the Privacy Notice.

Follow the steps to complete the form effectively.

1. Press the ‘Get Form’ button to access the Privacy Notice Acknowledgment Form and open it for editing.
2. Begin filling out the form by entering the patient's name in the designated field labeled 'Patient Name.' This is important for identifying the individual who is acknowledging receipt of the privacy notice.
3. Next, input the medical record number in the 'Medical Record Number' field. This number helps to link the acknowledgment to the patient's medical records.
4. In the section where it states 'By signing this form,' read the statement carefully. This indicates that you have received the Privacy Notice and understand your rights. You may review the Privacy Notice before signing.
5. To acknowledge receipt, sign your name in the 'Signature of Patient Or Legal Representative' field. If you are signing on behalf of another person, ensure you have the legal authority to do so.
6. Enter the date of signing in the 'Date' field. This is crucial for record-keeping purposes.
7. If you are not the patient, provide your relationship to the patient in the 'Relationship, if not the patient' section. This helps clarify your connection to the individual.
8. Review your entries to ensure all required fields are completed accurately.
9. After filling out and signing the form, save your changes, and consider downloading, printing, or sharing the completed document as needed.

Complete your Privacy Notice Acknowledgment Form online today to ensure proper health care documentation.