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Acknowledgement of Receipt of “Notice of Privacy Practices”


Client Name: D.O.B  

Maiden or Other Name (if applicable):  

I acknowledge that I have been provided a copy of Compassionate Homecare of South Florida, LLC’s  Notice of Privacy Practices, which describes how they may use and disclose my Protected Health Information during the performance of their operations; and, explains my rights & responsibilities and their responsibilities in respect to my Protected Health Information. In addition, CHSFL have explained the US Advance Directives Information Sheet for the State of Florida and I acknowledge I have the right to a personal healthcare surrogate or proxy.  A copy of the information sheet is in my client handbook.

I understand that Compassionate Homecare of South Florida, LLC has the right to change the Notice of Privacy Practices at any time as per HIPAA request and that revised editions will be posted on their Website and at their Agency Office.  I also understand that I may request a copy of the updated version in person, via phone, via email or via regular mail.


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Signature Certificate
Document name: Acknowledgement of Receipt of “Notice of Privacy Practices”
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December 18, 2023 2:02 pm GMTAcknowledgement of Receipt of “Notice of Privacy Practices” Uploaded by John Smith - smitch@chsfl.co IP 202.47.33.79
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