Sickle Cell Disease Foundation of California

Acknowledgement of Receipt of Notice of Privacy Practices

By my signature below, I ________________________________________________________, acknowledge

that I have received a copy of the Notice of Privacy Practices for the Sickle Cell Disease Foundation of California.

_________________________________________             ______________________________

Signature of client (or personal representative)                         Date

If this acknowledgement is signed by a personal representative on behalf of the client, complete the following:

Personal representative’s Name: ________________________________________________________

Relationship to Client: _________________________________________________________________ 

For Office Use Only

We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because:

            q      Individual refused to sign

            q      Communication barriers prohibited obtaining the acknowledgement

            q      An emergency situation prevented us from obtaining acknowledgement

            q      Other (specify)  _______________________________________________________

                        __________________________________________________________________

                        __________________________________________________________________

_________________________________________              ______________________________

Signature of Authorized SCDFC Personnel                                Date