Acknowledgment of Notice of Privacy Practices

My signature below indicates that I have been given an opportunity to read the Notice Of Privacy Practices for the Fulton County Health Department, and to have any questions answered before signing.

Signed(Required)

Date(Required)

Print Name(Required)

If signed by someone other than the patient, please indicate relationship to patient

Parent or guardian of minor patient

Guardian or conservator of an incompetent patient

Beneficiary or personal representative of deceased patient