Adult Protective Services Policy Manual
Privacy Policies Acknowledgement Form Instructions
1707.60
PURPOSE:
The Acknowledgement Form provides the Department of Health and Senior Services (DHSS) the necessary documentation for purposes of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). The form documents the Reported Adult’s (RA’s) receipt of the Department’s Notice of Privacy Policies explaining how the Department may use and/or disclose the RA’s medical information. The Privacy Policies Acknowledgement Form is located in this manual, and it can also be found in Case Compass. The Department’s Notice of Privacy Policies can be found on the DHSS intranet. Click on “Resources” and then click on “HIPAA” to locate the notice.
If anAdult Protective Service (APS) investigation involving an RA is closed and a subsequent report is received, the RA must sign a new Acknowledgement Form and be provided with a current copy of the Department’s Notice of Privacy Policies.
NUMBER OF COPIES:
One copy is required.
INSTRUCTIONS:
All RAsshall sign the Acknowledgement Form and be given the Notice of Privacy Policies at initial contact, if at all possible.
- Print the RA’s first name, middle initial and last name.
- Print the RA’s birth month, day and year.
- Print the RA’s social security number.
- Print the RA’s Departmental Client Number (DCN) if applicable.
Have the person who is receiving the Notice of Privacy Policies print their first name, middle initial and last name. This will be the RA, their legal guardian or any individual to whom the RAhas given Durable Power of Attorney for Health Care (DPOA-HC).
If the person who signs the Acknowledgement Form is the guardian or DPOA-HC, a copy of the Letters Appointing the Guardian or a copy of the DPOA-HC shall be attached to the Acknowledgement Form.
Obtain the signature of the person who printed their name on the line and have that individual date the form. RAs who cannot sign may mark with an “X.”
Check the appropriate box to describe the relationship between the RAand the person who signed the Acknowledgement Form.
If the RA refuses to sign the form, the Adult Protective Community Worker (APCW) shall check the box “client refused to sign form.”
If the APCW is present when the Acknowledgement Form is completed, sign and date the form.
Any time an Acknowledgement Form is mailed to the RA(or their guardian or DPOA-HC) for signature, the APCWshall enclose a self-addressed, stamped envelope to have the form returned to theAPCW.
DISTRIBUTION:
The original signedacknowledgement form shall be scanned and uploaded to the RA’s electronic record in Case Compass. Upon request, a copy shall be given to the client.
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Effective: 10/13