RESIDENT ACKNOWLEDGMENT OF RECEIPT OF

NOTICE OF PRIVACY PRACTICES OF

CREST HAVEN NURSING AND REHABILITATION CENTER 

By signing this acknowledgment, I am acknowledging that Crest Haven Nursing and Rehabilitation Center  provided to me a copy of its “Notice of Privacy Practices.” 

I understand that under New Jersey law, Crest Haven is required to obtain my “approval” prior to its releasing my information to anyone outside the nursing home EXCEPT for cases where I transfer to another health care facility, or unless the release is required by law, a third-party payment contract, or the New Jersey State Department of Health and Senior Services.

By initialing below, I give my “approval” to allow Crest Haven to use and disclose my Health Information as set forth in the Notice of Privacy Practices.  I understand that I have the right to withhold my approval for all disclosures other than as set forth above and may exercise that right by refusing to initial in the space below. I also understand that I may request a restriction the use and disclosure of my Health Information at any time, for any Health Information. The process for requesting such a restriction and Crest Haven’s obligations are set forth in this Notice.

____________________

Initials for Disclosure in

Accordance with Notice of

Privacy Practices

 I received a copy of the “Notice of Privacy Practices” of Crest Haven Nursing and Rehabilitation Center. 

Signed By: ________________________               __________________________

Signature of Resident or Responsible Party                Relationship to Resident

________________________                                  ___________________________

Resident’s Name                                                        Date 

________________________                                  ___________________________

Witness                                                                      Date