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Whitehall Boca Raton's
Acknowledgement of Receipt of Notice of Privacy Practices

I certify that I have received a copy of Notice of Privacy Practices.  The Notice of Privacy Practices describes the types of uses and disclosures of my protected health information that might occur in my treatment, payment of my bills or in the performance of Whitehall Boca Raton’s health care operations.  The Notice of Privacy Practices also describes my rights and Whitehall Boca Raton’s duties with respect to my protected health information.  The Notice of Privacy Practices is posted in the front entrance of the facility and on Whitehall Boca Raton’s website (http://www.whitehallboca.com).

Whitehall Boca Raton reserves the right to change the privacy practices that are described in the Notice of Privacy Practices.  I may obtain a revised Notice of Privacy Practices by calling the facility and requesting a revised copy be sent in the mail, asking for one in person, or accessing Whitehall Boca Raton’s website.

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Name of Resident (Print)

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Signature of Resident or Personal Representative

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Name of Resident or Personal Representative  (Print)

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Date

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Description of Personal Representative’s Authority

Whitehall Boca Raton, 7300 Del Prado South, Boca Raton, FL 33433
Phone: (561) 395-8824; Fax: (561) 395-8824