HIPPA Acknowledgement


                                                                                                                                                                                 

 

 

                                                                         [Place Patient Label Here]

 

St. Vincent's Health System

 

Acknowledgement of Receipt of Joint Notice of Health Information Privacy Practices

By signing below, I acknowledge that I have received St. Vincent's Joint Notice of Health Information Privacy Practices

 

Name of Patient or Legal Representative                                      

Date



Notice Effective Date July 1, 2007

VINCENT'S HEALTH SYSTEM


St. Vincent's Hospital Birmingham

810 St Vincent's Drive, Birmingham, Alabama 35205

St. Vincent's Hospital East

50 Medical Park Drive East, Birmingham, Alabama 35235

St. Vincent's Hospital St. Clair

7063 Veterans Parkway, Pell City, Al 35125

St. Vincent's Hospital Blount

150 Gilbreath Drive, Oneonta, Alabama 35121

One Nineteen Health and Wellness Center

7191 Cahaba Valley Road, Hoover, Alabama 35242

 

8630-013 Revised JutY/07

{W0148499.1 \ 00102-05700}                           

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Document name: HIPPA Acknowledgement
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January 22, 2021 11:38 am CDTHIPPA Acknowledgement Uploaded by Dylan Richardson - dylan@danmarkcom.com IP 12.233.60.59
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