Livingston County Health Department

P.O. Box 650, 310 E. Torrance

Pontiac, IL 61764

Phone: 815-844-7174   Fax: 815 844-7468

CONSENT and ACKNOWLEDGMENT

Receipt of Joint Notice of Privacy Practices

I, do hereby consent to allow the health department and its designated employees and contractors to enroll/provide services thru their programs.

I understand the nature and consequences of any procedures to be performed will be explained to me.

I understand that the health department is already authorized to use the information gained during treatment to bill me, my insurance company, or any other potential sources of reimbursement, such as government programs in which I am enrolled or qualify for services.

I also hereby acknowledge that I received a copy of the “Joint Notice of Privacy Practices” from the health department dated April 14, 2003.

I also hereby acknowledge that I have received the following other privacy notices:

_______________Illinois Department of Human Services Cornerstone Notice of Privacy Practices

          (Date)

                                                                           ____________________________________

Child’s name (if a minor)                                       Printed Name

                                                                           ___________________________________

Birthday of client                                                    Signed

        ___________________________

        Date

Check if any of the following apply:

¨            Parent or Guardian of minor                              ¨            Health Care Surrogate

¨            Power of Attorney for Health Care                         ¨            Mental Health Treatment Preference Declaration Agent

¨            Guardian with power to make health care decisions

-------------------------------------------------------------------------------------------------------------------------------------------------------------------

FOR STAFF USE ONLY:

I attempted to obtain an Acknowledgment of the Receipt of the Notice of Privacy Practices on behalf of the HD.  The HD was unable to obtain the Acknowledgment because:

¨    Client refuses to sign            ¨      Other (specify)                                                    

                                                      (Staff’s Signature)                                    (Date)