Midland County, MI · Midland County
Privacy Practices Acknowledgement of Receipt
This form records that a patient or personal representative received the Midland County Department of Public Health Notice of Privacy Practices.
At a glance
- Issued by
- City of Midland County · Midland County, Midland County, Michigan
- Notarization
- Not required: file this form without a notary.
- Official source
- midlandcountymi.gov
- Blank form
- Download the PDF
- Catalogued
- Machine-readable
- JSON record · about the forms index
What this form is
Patients use this form to acknowledge receiving a copy of the Midland County Department of Public Health Notice of Privacy Practices. The patient prints and signs their name and dates the form; a personal representative can do so instead and provide their relationship to the patient. If neither signs, a department employee records the good-faith effort and reason the acknowledgement could not be obtained.
Who needs it
A patient receiving the department’s Notice of Privacy Practices, or their personal representative, signs this acknowledgement for the patient’s medical record.
How to submit it
The form says it should be placed in the patient’s medical record. Check with the Midland County Department of Public Health for current contact details and handling instructions.
About notarization
This document is signed without a notary; the patient or personal representative signs and dates it, or staff records the reason an acknowledgement could not be obtained.
How to submit this form
- 1
Download the Form
Download the Privacy Practices Acknowledgement of Receipt.
- 2
Complete the Acknowledgement
Print and sign your name and date the form, or have the patient’s personal representative complete and sign it.
- 3
Provide Representative Details
If a personal representative signs, enter their relationship to the patient.
- 4
Place It in the Medical Record
The form says it should be placed in the patient’s medical record; check with the department for handling instructions.
Frequently asked questions
- Do I need a notary for the Privacy Practices Acknowledgement?
- No. The patient or personal representative signs and dates this form without a notary. If neither signs, staff can document the reason the acknowledgement could not be obtained.
- Who signs the acknowledgement?
- The patient may print and sign their name and date the form. A personal representative may sign instead and must also provide their relationship to the patient.
- How do I submit the Privacy Practices Acknowledgement?
- The form says it should be placed in the patient’s medical record. Check with the Midland County Department of Public Health for current contact details and handling instructions.