NOTICE OF PRIVACY PRACTICES ACKNOWLEDGMENT
I have read and agree to this Notice of Privacy Practices.
Print Name ___________________________
FOR HOSPITAL INPATIENTS-YOUR CHILD'S INFORMATION WILL BE RELEASED FROM THE PATIENT DIRECTORY UNLESS YOU COMPLETE THIS SECTION.
IF YOU DO NOT WANT YOUR CHILD'S INFORMATION RELEASED FROM THE PATIENT DIRECTORY, THEN PLEASE READ BELOW CAREFULLY.
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.
___________ 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.