Acknowledgement of Notice of Privacy Practices

     

    Client Name: ________________________________

    Date of Birth: _______________

    I have been given or offered a copy of New Haven Youth and Family Services’ current Notice of Privacy Practices (“Notice”), which describes how Protected Health Information (“PHI”) and student records is used and shared.  I understand that New Haven has the right to change this Notice at any time.  I may obtain a current copy by contacting New Haven’s Privacy Officer or by visiting the New Haven website at https://newhavenprod.wpengine.com/privacy/

    My signature below acknowledges that I have been provided with or offered a copy of Privacy Practices:

     

    For clients who are minors:

    ________________________________         ________________

    Signature of Parent, Guardian, or Representative     Date

     

    For clients who are non-minors:

    ________________________________         ________________

    Signature of Youth                                                            Date

     

    ________________________________         _________________

    Signature of NHYFS Representative                             Date

    New Haven use: Complete this section if you are unable to obtain a signature:

    1. If the client or parent/legal guardian is unable or unwilling to sign this Acknowledgement, or the Acknowledgement is not signed for any other reason, state the reason:___________________________________________
    2. Describe the steps take to obtain the client’s or parent/legal guardian’s signature on the Acknowledgement: _________________________________________________

     

    Completed by:

    ____________________________   ________________

    Signature of New Haven Representative     Date

     

    __________________________________

    Printed Name of New Haven Representative