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Click here to download Patient/Parent HIPAA Information
CHILDREN'S HEALTH SYSTEM
NOTICE OF PRIVACY PRACTICES
Effective October 2, 2006
Privacy Practices (PDF Version)
Privacy Practices (Spanish PDF Version)
NOTICE OF PRIVACY PRACTICES ACKNOWLEDGMENT
I have read and agree to this Notice of Privacy Practices.
Date:____________________
Print Name:___________________________
Signature:____________________________
** FOR HOSPITAL INPATIENTS-YOUR CHILD'S INFORMATION WILL BE RELEASED FROM THE PATIENT DIRECTORY UNLESS YOU COMPLETE THIS SECTION.**
I understand that I have the right to NOT release my child's information from the Patient Directory for Hospital Inpatients. This means that my child's name, location in the hospital, or general condition will NOT be released to people who ask for my child by name or my child's religious affiliation provided to members of the clergy.
This could prevent family, friends, or clergy from finding my child or deliveries to be made to my child.
Please initial
___________ I wish for my child's information to NOT be released from the Patient Directory.
___________ I wish for my child's information to NOT be released to the press/media if requested.
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