Acknowledgement of Receipt of Important Information ...
ACKNOWLEDGEMENT OF RECEIPT OF IMPORTANT INFORMATION REGARDING PRIVACY AND RIGHTSI have received the following information: Version Received FORMCHECKBOX Tennessen Notice (DAK 2519.01) – Information about informed choice about whether or not you will provide protected/private information and how we need to protect your private information.01/11/05 FORMCHECKBOX Minnesota Department of Human Services Notice of Privacy Rights (DHS-3979) - Information about how medical and other private information about you may be used and disclosed and how you can get this information.8/2011 FORMCHECKBOX Your Appeal Rights – (DHS -1941) – Information regarding your right to appeal state or county action and your right for a fair hearing by the state.5/2011 FORMCHECKBOX Acknowledgement of Services Options and Client Selections (DAK 7060) – Dakota County wants you to know you have the right to choose your provider who have met state requirements.12/2013 FORMCHECKBOX Dakota County Health Care Components Notice of Privacy Practices (DCPHD-GN-965) (HIPPA) – How medical information and other private information about you may be used and disclosed and how you can get access to this information.3/22/10I acknowledge I have been informed and received the explanation of the above information. I acknowledge I have received copies of the forms above.Client Name FORMTEXT ?????Parent/Legal Guardian SignatureDATECounty Worker SignatureDATE ................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.
Related download
- notice and acknowledgment of receipt family law fl 117
- attachment 4 acknowledgement of receipt of appeal
- acknowledgement of receipt documents
- acknowledgement of receipt uwsp
- acknowledgement sample
- form 42 affidavit of proof of service
- acknowledgement of receipt of company property financial
- resignation acknowledgement letter
- acknowledgement of receipt
- how to prepare a notice and acknowledgement of receipt
Related searches
- important information synonym
- important information for senior citizens
- letter acknowledgement of great work
- notice of acknowledgement of pay rate 2019
- acknowledge receipt of your email
- acknowledgement of receipt letter
- notice of acknowledgement of receipt
- notice and acknowledgment of receipt civil
- notice and acknowledgement of receipt california
- confirming receipt of an email
- email acknowledging receipt of document
- acknowledge receipt of email sample