ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
I hereby acknowledge that I have received the attached Notice of Privacy Practices of Renown Health .
_________________________________________ Signature of patient or personal representative
________________________ Relationship to patient
_________________________________________ Print name
________________________ Date
FOR RENOWN USE ONLY
Reason acknowledgement was not obtained : ___________________________________________________________________________
___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________
Renown employee completing this form ( Please print ): _________________________________ Date : __________________________ Renown Entity : ______________________________________________________________ Scan form to : HIPAA
Audit and Compliance 1155 Mill St ., MS N-14
Reno , NV 89502 775-982-8300
Patient Label
Form Number : 100-012
Effective April 2004 Revision History : 1 / 2023 ; 6 / 2022 ; 1 / 2021 ; 3 / 2018 ; 7 / 2015 Revision ; 3 / 2007 Date : 1 / 2023