RECEIPT OF PRIVACY PRACTICES by pp00pp

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									                                                   Eastpointe
 2901 North Herritage St.          P. O. Box 599                    P. O. Box 47                 100 South James Street
    Kinston, NC 28501          Kenansville, NC 28349             Clinton, NC 28329                 Goldsboro, NC 27530
Telephone: (252) 527-7086    Telephone: (910) 296-1851      Telephone: (910) 592-5791          Telephone: (919) 731-1133
   Fax: (252) 523-3262          Fax: (910) 296-1731            Fax: (910) 592-5087                Fax: (919) 731-1333




                            RECEIPT OF PRIVACY PRACTICES


                •   I acknowledge that I have been informed of Privacy Practices for Eastpointe.

                •   I understand that the Privacy Practices brochure discusses how my personal
                    health care information may be used and/or disclosed, what my rights with
                    respect to health care information are, and how and where I may file a privacy-
                    related complaint.

                •   I understand that I may obtain a copy of this brochure from the agency website,
                    www.eastpointe.net, and/or by requesting one from agency staff and/or the
                    Privacy Officer;

                •   I understand that this brochure may be changed in the future, and these
                    changes will be posted in the waiting room of the agency, and/or posted on
                    the agency website (as noted above). I may also request a copy of the new
                    brochure by contacting the Privacy Officer at the telephone number listed
                    above.




             ______________________________________________                             ________________
             CLIENT’S NAME (PLEASE PRINT FULL NAME)                                     DATE OF BIRTH



             ______________________________________________                             ________________
             CLIENT’S/LEGALLY RESPONSIBLE PERSON’S SIGNATURE                            DATE




                                                                                           Effective Date: 4-14-2003
                                                                                                     Revised: 9-1-04

								
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