Documentation of Good Faith Efforts

Documentation of Good Faith Efforts
To obtain patient’s acknowledgment that they received provider’s
Notice of Privacy Practices

(For use when acknowledgment cannot be obtained from the patient.)

Patient Name: ____________________________________________________________

The patient presented to the office/hospital on [insert date] and was provided with a copy of Covered Entity's Notice of Privacy Practices. A good faith effort was made to obtain from the patient a written acknowledgment of his/her receipt of the Notice. However, such acknowledgement was not obtained because:

	Patient refused to sign.
	Patient was unable to sign or initial because: __________________________________________ __________________________________________
	Patient was unable to sign or initial because:
	Other reason (describe below): __________________________________________ __________________________________________

Signature of Employee Completing Form: ________________________________

[Note: Providers are required to make good faith efforts to obtain acknowledgement that each patient has received their Notice of Privacy Practices. Should the individual refuse to acknowledge receipt of provider’s Notice of Privacy Practices, the provider should document the “Good Faith Efforts” taken to obtain such acknowledgement. The regulation does not specify how those “Good Faith Efforts” should be documented. This example form is meant to serve as an example of one way that a provider could satisfy this requirement.]

(Document provided to MIEC policyholders with permission from
Physician Insurers Association of America)

Return to MIEC HIPAA "Starter Kit"