Smith Clinic/Marion Area Health Center

Acknowledgment of Receipt of Notice of Privacy Practices

This is to acknowledge that Smith Clinic/Marion Area Health Center’s Notice of Privacy Practices (effective date April 14, 2003) has been made available to me on the date stated below.

_______________________________________ Date of Patient’s or Personal Representative’s Signature _______________________________________ Patient’s Date of Birth

_______________________________________ Signature of Patient or Personal Representative _______________________________________ Please Print Patient’s Name _______________________________________ _______________________________________ Patient’s Address _______________________________________ Name of Personal Representative (If applicable) _______________________________________ _______________________________________ Description of Representative’s Authority to Act for the Patient (If applicable)