Notice of Privacy/Acknowledge of Receipt 2-Pt Form
Describe to residents how medical information about them may be used and disclosed and who has access to the information. Includes 2-part Acknowledgement of Receipt (detachable) to quickly and easily obtain a signature and document receipt.
9" x 11", 4-page booklet-style form (white bond paper, printed two sides different) plus an attached 2-part carbonless form (white original, yellow duplicate, printed one side), black ink, 5-hole punched top and side, wrapped in 100s.