Notice of Privacy Practice Receipt

							                               NOTICE OF PRIVACY PRACTICES RECEIPT



______ I acknowledge that I have received a copy of the Wyandotte County Public Health
Department’s Notice of Privacy Practices with the effective date of April 14, 2003.

_______ Yo acepto que recibi una copia del Departamento de Salud de Condado Wyandotte de la
Notificacion de la Practica de Privacidad que sera efectivo el dia 14 de Abril del 2003.



________________________________________________________________                   _____________

Signature of Patient/Patient Representative                                        Date/Fecha
Firma de Paciente/El Representante de Paciente

________________________________________________________________
Relationship to Patient
Relacion del Paciente




                                          Office Use Only

 Print Name:___________________________________________________ Date:___________

 The patient was provided with a copy of the Wyandotte Public Health Department’s Notice of
 Privacy Practices on the date noted above. A good faith effort was made to obtain from the
 patient a written acknowledgement of his/her receipt of the Notice. However, such
 acknowledegment was not obtained because:

         Patient refused to sign _______
         Patient was unable to sign because__________________________________________

 Signature of employee completing form:_____________________________________________



*Original to be maintained in patient’s permanent medical record