FILL & PRINT • PATIENT WORKSHEET

Privacy notice acknowledgment

Complete only after receiving Swift’s actual Notice of Privacy Practices. Print and sign by hand.

Your answers are not submitted.

Fill out what you can, then print or save as PDF using your device’s print menu. Bring it to your visit. Nothing is sent to Swift. Closing or refreshing this page can clear your work.

Swift Rehabilitation, Inc.Maryland: (443) 323-0027 / (443) 469-3426 · New Jersey: (856) 856-4122

Receive the notice first.

Swift must provide its actual clinical Notice of Privacy Practices before you acknowledge receipt. This website’s privacy policy is not that notice. Call Swift if you have not received a copy.

Patient’s full nameDate of birthNotice effective / revision date (from the notice)Date notice was receivedRepresentative name and relationship (if applicable)

I acknowledge that I received Swift Rehabilitation’s Notice of Privacy Practices describing how health information may be used and shared and how I may exercise my privacy rights. My signature acknowledges receipt; it does not authorize additional disclosures or waive my rights.

If I do not wish to sign, I can discuss this with Swift. Staff may document their effort to provide the notice and obtain acknowledgment.

For staff completion

Notice provided by: ____________________ Date: ____________________

If acknowledgment was not obtained, document the attempt and reason:

_____________________________________________________________________

Reference: HHS Notice of Privacy Practices ↗.

Patient / representative signature: ___________________________________

Date: ____________________ Relationship (if applicable): ____________________

This worksheet is for discussion with Swift. It does not confirm an appointment, establish treatment consent, or authorize release of records.

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