Get Attachment D2

Filling out the ATTACHMENT D2 is an essential part of acknowledging the Notice of Privacy Practices as required by the Department of Health. This step-by-step guide will help you complete the form accurately and efficiently, ensuring that you understand each component.

Follow the steps to complete the ATTACHMENT D2 online.

1. Press the ‘Get Form’ button to access the document and open it in your browser.
2. Start by entering your name in the designated field marked 'Name' and your client ID number in the 'Client ID#' field.
3. In the 'Facility/Site/Program' section, fill in the name of the facility or program you are affiliated with.
4. You must indicate that you have received a copy of the Department of Health Notice of Privacy Practices by selecting the appropriate checkbox.
5. Provide your signature in the 'Signature' field, along with the date in the 'Date' field.
6. If you are signing on behalf of someone else, print your name in the 'Print Name' section and specify your role (e.g., parent or guardian) in the 'Role' field.
7. A witness must sign and date the form in the respective sections. Ensure that they write their name clearly.
8. If the acknowledgment was not obtained, document how the notice was given in the space provided, indicating the date and method (e.g., face-to-face, mailing, email).
9. Indicate the reason why the individual or their representative did not sign the form by checking the appropriate box or describing the reason in detail.
10. Document any good faith efforts that were made to obtain the signature, including dates and outcomes of attempts, in the provided section.
11. Finally, staff members must sign and print their name, along with their title and the date in the respective fields.
12. After completing the form, save your changes, download, print, or share the document as needed.

Start completing the ATTACHMENT D2 online today for a seamless documentation process.