Fillable ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES (The Chickasaw Nation)

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ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES (The Chickasaw Nation)

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ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF
PRIVACY PRACTICES
A"complete"description"of"how"your"medical"information"will"be"used"and"disclosed"by"the"Chickasaw"
Nation"Refill"Center"is"in"our"NO T IC E "OF"PRIVACY"PRA CTICES."T h e "n o tic e "is"p o s ted"throug h o u t"o u r "
facility"and"you"will"be"given "a"cop y"for"yo ur"pe rso nal"use ."
I!have!rec e ive d !a !co p y !of!the!Chickasaw!Nation!Refill!Center!Notice!of!Privacy!Practices!dated!April!01,!
2016.!
Patient!name!(please!print)! !Patient!date!of!birth!
Patient!or!representative!-!signature!
!Legal!representative!signature!!!!!!!!!
Date!signed!
Basis!for!refusal,!if!refused:!
Chickasaw Nation Refill Center
Native & Non-Native Spouse Prescription Program
933 N. Country Club Road
Ada, OK 74820
CNRefillCenter@Chickasaw.net
For
m no. 02905A TCH-RC 4/2016
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ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES (The Chickasaw Nation)

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Completed 31 January 2021

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