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 / 2025; 1 / 2023; 1 / 2021; 3 / 2018; 7 / 2015; 3 / 2007